Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Medical Director

📁
Director and Equivalent
📅
190WS Requisition #
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Manages the daily clinical operation and administration of a Medical Management Department or function to support improved utilization results.  Provides clinical leadership both internally and externally.  Serves as an essential liaison among Senior Management, Plan staff, contracted providers, vendors, and membership to promote and improve communication and operations.  Carries out assigned programs to assure the delivery of quality medical care to the EmblemHealth membership, ensures compliance with contractual obligations and standards, assists in the development and implementation of new policy and programs as needed.  Ensures operational effectiveness and oversight of assigned functions, assuring regulatory compliance and accreditation with Department of Health, Department of Insurance, CMS, NCQA, and URAC standards.

Responsibilities:
  • Manages use of medical resources for inpatient and outpatient services; determines medical appropriateness through the application of clinical criteria; performs case management review; and, participates in the clinical appeals process.  Sole authority and responsibility for issuing clinical adverse determinations based on medical necessity. Conducts medical rounds, attends Medical Director meetings and participates in the inter-rater reliability process. May also perform peer clinical reviews as needed. (See Addendum for expanded description of this activity)
  • Establishes and maintains continuity in the planning, development and implementation of policies, operational processes, workflows required to execute organizational strategies and to assure consistency in process application throughout Care Management.  Validates and monitors adherence to implemented policies, procedures, workflows and processes:  identifies, recommends and implements improvement initiatives accordingly.  Generates methods to develop and improve the overall delivery and performance of the department.  Implements process improvements in a timely manner.  Deals effectively with and leads others throughout Company structure.  Supports other areas in implementing cross-departmental changes.  Makes sound decisions based on all available data. Determines medical appropriateness through the application of clinical criteria and performs case management review.
  • Develops annual goals and oversight of assigned department/function.
  • Supports Senior Medical Directors in communications with internal and external organizational goals; ensures a high level of customer satisfaction (members, vendors, providers, regulators, accreditation agencies, peers and employees).
  • Anticipates and identifies key source information to analyze problems clearly and determines creative solutions.  Identifies trends, problems and opportunities, conducts root cause analysis.  Implements action plans in an effective and efficient manner aimed at promoting goals/resolving barrier issues.  Strives to improve efficiencies of key operational areas.  Assists with contract negations as necessary.  Represents Care Management in interdepartmental committees designed to meet organizational goals.
  • Chairs or participates on committees as requested.
  • Regular attendance is an essential function of the job.  Performs other duties as assigned or required.
Qualifications:
  • MD or DO degree. Board certification is required
  • Active New York license or certification to practice medicine without restriction required
  • 5 years of clinical practice required
  • Administrative experience on a hospital committee, in a medical group or for an insurer preferred
  • Knowledge of clinical practice of medicine, health care delivery systems, utilization methods and treatment
  • Protocols required
  • Knowledge and understanding of managed care principles, industry evolution, physician reimbursement, and human resource management required
  • Considerable independent decision making with physicians, members, subordinates, other departmental leaders and external vendors, regulatory and accreditation agencies required
  • Communication skills both oral and written, tact and diplomacy sufficient to successfully carry out the above duties and responsibilities required
  • Knowledge of clinical practice of medicine, health care delivery systems, utilization methods and treatment protocols required

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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