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To be fully engaged in providing Quality/No Harm, Customer Experience, and Stewardship. The Medical Director of Health First Health Plans plays a criticalrole in the success of the medical delivery and medical cost management areasof the organization. The Medical Director will coordinate with the HFHP Chief Medical Officer to continually develop and drive innovative strategies that focuson improving health and managing costs. In addition to being responsible for theongoing and successful implementation of care management and costcontainment programs, the medical director will work with system-wide and community physicians to drive efficiencies and outcomes using utilizationmanagement, disease management, population management, and evidence-based care programs
Functions as the frontline medical cost manager and advisor to the senior level organization officers in the areas of medical cost control, utilization management and medical claims review
Facilitates the implementation of the organizations mission and executionof the overall strategic goals through the development of managed careprograms and strategic plans as described by Senior Leadership.
Establish and implement medical policy and procedure guidelines forproviders and gain the support of providers for the implementation ofmanaged care programs.
Responsible for medical policy development and oversight as it relates to utilization review.
Review data analytics as generated by medical policies and formulate strategies to address over/under utilization, best practices, and cost containment.
Functions as a key liaison between the medical providers andadministrative arms of the organization
Provides guidance for all clinical operational aspects of the program.
Oversees Medical Policy Department and others as determined.
Collaborates in the development and implementation of system-wide bestpractices for quality driven Care Management for Health First and itsaffiliated entities.
Partner with the system’s medical directors to educate physicians on keyutilization management initiatives.
Collaborates with community providers (SNF’s, LTAC’s, Home HealthCare, Hospice, and Physicians) to promote coordination of care andimprove quality outcomes.
Provide daily medical support and appropriate direction to utilization review staff on issues pertaining to prior authorization, concurrent and retrospective review.
Provide feedback to attending physicians regarding U/M issues, questionable patterns of utilization for inpatient, outpatient and ancillary services as identified in ongoing reviews or retrospective utilization data.
Work independently or with physician departmental leadership to resolve issues relating to outlier physician behavior.
Set standards and oversee the installation of a system for monitoring physician practice patterns in terms of production, clinical outcomes and patient satisfaction.
Conducts peer clinical review for cases as needed for quality and claims departments.
Conducts regular rounds with UM Nurses to discuss cases and provide communication regarding problematic case types.
Ensures that relevant policies and procedures as well as CMS, NCQA, state and federal program requirements are implemented to achieve effective, efficient, auditable, and compliant operations.
Interprets existing policies and develops new policies based on changes in the healthcare or medical arena.
Assist in public relations functions where appropriate with the local medical community, organized medical societies and community organizations, and promote the organizations managed care products.
Coach and counsel physicians regarding clinical and/or interpersonal skills. Function as a teacher and role model for the rest of the physician network demonstrating expected physician behavior.
Participate in key marketing activities/presentations where needed for product enhancement and integration of clinical programs.
Collaborate with system leadership to develop and implement programs system-wide that manage toward population wellness, disease mitigation and disease management.
Participates in formulating health services utilization and cost forecasts with responsibility for monitoring, developing and executing controls designed to meet budgeted targets based on the cost of delivering medical care. Participates in annual budget process for his/her area of responsibility and monitors financial performance monthly with senior leadership.
Establish case management criteria for high intensity/cost diagnoses and identify potentially large cases for cost management through the use of established case management techniques. (Criteria are reviewed and updated as needed at least annually).
Assist CMO with clinical integration throughout Health First.
Represent HFHP in appeal hearings.
Assist with the implementation of value based contracting that reduces medical cost trends and improves quality metrics as guided by the CMO.
Provides guidance for all programs related to authorization (pre-certification) of services.
Responsible for utilization review/ authorizations for medical management and pharmacy.
This position requires a M.D. or DO degree from an accredited program along with American Board Certification.
Approved residency in a broad specialty such as Internal Medicine, Family Practice, Pediatrics, General Surgery or Obstetrics/Gynecology
Very strong management skills, and prior management experience.
Excellent communication skills with a demonstrated ability to communicate and work effectively with physicians and administrators.
An advanced degree in business, management or healthcare management would be preferred.
A minimum of 5 years in successful medical practice with a minimum of 3 years working within a medical group environment.
A current, unrestricted Florida medical license.
Positive experience in a variety of leadership roles to include such activities as Assistant Medical
Director, Chairperson of Medical committees, etc.
Experience in the design and implementation of UR/QA programs and managed healthcare delivery systems.
Health First is Central Florida's only fully integrated health system. With a mission to positively change the health and wellness of the communities we serve, Health First offers the latest technological advances and quality care at our four hospitals and through our many Outpatient & Wellness Services, as well as the area's only Trauma and Heart Centers. Health First also offers multiple commerc...ial and Medicare health plans, the largest multi-specialty physician group in Brevard County, and four fitness centers to help members of our community stay healthy.