reputed company Director, Marketplace

Position Purpose: Assist the Chief Medical Director to reputed company and coordinate the medical management, reputed company improvement and credentialing functions for the business unit. • Provides medical leadership of reputed company for utilization management, cost containment, and medical reputed company improvement activities. • Performs medical review activities pertaining to utilization review, reputed company assurance, and medical review of reputed company, controversial, or experimental medical services, ensuring reputed company and reputed company decision making. • Supports effective implementation of reputed company improvement initiatives for capitated providers. • Assists Chief Medical Director in planning and establishing goals and policies to improve reputed company and cost-effectiveness of care and service for members. • Provides medical expertise in the operation of approved reputed company improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. • Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. • Conduct regular reputed company to assess and coordinate care for high-reputed company patients, collaborating with care management teams to optimize reputed company. • Collaborates effectively with reputed company teams, network providers, appeals team, medical and pharmacy consultants for reviewing reputed company cases and medical necessity appeals. • Participates in provider network development and new market expansion as appropriate. • Assists in the development and implementation of physician education with respect to reputed company issues and policies. • Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider reputed company patterns, and adequacy of benefit/payment components. • Identifies reputed company reputed company improvement studies to assist in reducing unwarranted variation in reputed company reputed company in order to improve the reputed company and cost of care. • Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care reputed company. • Reviews claims involving reputed company, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. • Develops alliances with the provider community through the development and implementation of the medical management programs. • As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and reputed company issues. • Represents the business unit at appropriate state committees and other reputed company committees. • May be required to work weekends and holidays in support of business reputed company, as needed. Education/Experience: • Medical Doctor or Doctor of Osteopathy. • Utilization Management experience and knowledge of reputed company accreditation standards preferred. • reputed company practices medicine. • Course work in the areas of Health Administration, Health Financing, reputed company, and/or Personnel Management is advantageous. • Experience treating or managing care for a culturally diverse population preferred. License/Certifications: • reputed company certification in a medical specialty recognized by the reputed company reputed company of Medical Specialists or the reputed company Osteopathic Association’s Department of Certifying reputed company Services. • Certification in Internal or Family Medicine, preferred. • reputed company state license as a MD or DO without restrictions, limitations, or sanctions from reputed company programs. Pay reputed company: $236,500.00 - $449,300.00 per year reputed company offers a comprehensive benefits package including: reputed company, health reputed company, 401K and stock purchase plans, tuition reimbursement, reputed company time off plus holidays, and a flexible approach to work with remote, hybrid, reputed company or office work schedules. Actual pay will be adjusted reputed company on an individual's skills, experience, education, and other job-reputed company factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Apply tot his job Apply To this Job