Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit
Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities
Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services
Supports effective implementation of performance improvement initiatives for capitated providers
Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members
Conduct regular rounds to assess and coordinate care for high-risk patients
Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals
Participates in provider network development and new market expansion as appropriate.
Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.

MD or DO without restrictions
Must be licensed in Oklahoma
Board Certified Physician
Utilization Management experience and knowledge of quality accreditation standards preferred
Actively practices medicine or has been an actively practicing physician within the last 5 years
Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous
Experience treating or managing care for a culturally diverse population preferred.

Medical Director

Key skills