This position is available for part-time or full-time applicants.
Under general direction of the Chief Medical Officer and the Senior Medical Director, the Medical Director is responsible for leadership, medical necessity reviews, and direction as assigned to promote policies and standards that lead to more efficient and appropriate delivery of quality health care to beneficiaries and staff.
*Make determinations of medical necessity by review of clinical records and direct contact with providers as necessary.
*Make determinations regarding the appropriateness and quality of care by review of clinical records and through direct contact with providers as necessary.
*Review prior authorization requests for medical services based on review of clinical data submitted, policy, and consistent with current Medical Professional Services Unit guidelines, and the currently available medical evidence.
*Review requests for Out of State (OOS) services according to the current OOS rules. Participate in developing relationships with Oklahoma medical schools specialists and private practice specialists to improve access and capacity for SoonerCare members to be treated in state where capability and capacity exist. Participate in SoonerCare Provider education directed at better understanding of and compliance with current OOS rules.
*Provide medical advice and review to the Program Integrity (PI) unit in conducting PI audits. Review PI audits in the reconsideration phase and participate as a medical witness in PI appeals.
*Research areas of medicine that are unfamiliar or require updating to ensure policies and procedures are based on evidence and the current standard of care.
*Become familiar with and develop relationships with the appropriate staff in other divisions in order to fulfill the responsibilities of medical director.
*Participate in the peer-to-peer email line by communicating with providers as assigned, providing information, guidance and possible solutions as appropriate.
*Summarize documentation and records for discussion internally and to present as needed at beneficiary appeals before the ALJ and other venues as directed.
*Provide clinical expertise and input as requested to Legal, Policy, Audits, Provider Services, Care Management, Behavioral Health and other divisions as requested and as appropriate to promote efficient delivery of and access to quality medical care.
*Regular and consistent attendance at the assigned work site, as well as the ability to perform all job related travel, is essential to successful performance in this position.
*Provide guidance and support to the Director of Quality Assurance regarding the quality of care delivered, determining quality of care and medical home standards and assist with claims review guidelines. Assists in education of providers on quality issues.
*Direct or support special projects related to quality improvement as assigned.
*Present cases and recommendations to the OHCA Quality Assurance Advisory Group and participate in those deliberations as requested.
*Provide support as needed to the Director of the Medical Authorization and Review Unit to ensure decisions are being made based on evidence based guidelines and agency policy.
*Review claims for beneficiaries in special categories, e.g. aliens, disabled, Soon to be Sooners, etc. to ensure they meet federal and state guidelines that include clinical decision making.
*Consult and coordinate with other organizations or agency medical directors, clinicians, administrators, etc. to promote the welfare of our beneficiaries.
*Advise and assist agency, based on clinical understanding of the services provided, in setting payment guidelines for special, new, or unusual services.
*Recommend allowable reimbursement levels for new procedures based on comparable procedures, if no RVU value has been established yet are determined medically necessary.
*Participate in periodic on-site operational compliance audits and readiness reviews and PCP/CM provider audits as assigned.
*Represent OHCA on the Medical Education Intervention Team (MEIT) committee of the federally mandated Quality Improvement Organization in order to ensure contracted providers are delivering an appropriate standard of care for our beneficiaries as directed.
*Prepare and deliver presentations to providers, advocates, committees, boards, legislators and other constituencies as required.
*Communicate agency policies and procedures to primary care providers, specialists, hospital staff and administrators, and other clinicians as needed. Address the issues raised by these providers either directly or by appropriate referral to other agency staff.
*Advise and assist Provider Services Unit in education and provider training.
*Identify issues that affect provider participation and ultimately member access to providers. Offer recommendations and promote policies and procedures that remove barriers to provider participation and lead to better access to care.
*Participate in special projects such as the Health Management Program and C-Section reduction project, participation in MMDN as requested.
*Other duties as assigned.
TRAVEL: Local and overnight travel by both public and private conveyance is an essential requirement of this position.
SUPERVISORY RESPONSIBILITIES: This position does not supervise.
MEDICAL DIRECTOR EDUCATION AND/OR EXPERIENCE:
Currently active MD or DO license in the state of Oklahoma AND At least 3 years of clinical practice
PREFERENCE MAY BE GIVEN TO CANDIDATES:
Supervisory experience in group physician/hospital environment
Experience and knowledge of Medicaid programs
Advance degree in related field
Previous experience in medical review
Previous experience as a medical director
Veterans preference points apply only for initial appointment in the classified service.
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