OBJECTIVE

Responsible for assisting the Regional Medical Director in providing the means, structure, and environment to most effectively and efficaciously utilize the resources that are available to ensure that all enrolled members have access to appropriate medical care, and are provided with opportunities for health promotion and health maintenance as an administration of their individual Health Plan benefits in conjunction with additional community resources identified as meeting member care needs.

SUMMARY

• Manage a panel of high utilizer patients, across all PODs, which are selected by the RMD and POD leaders with the goal of positively directing their care seeking value while decreasing unnecessary emergency department visits and hospitalizations. High utilizer patients will rotate off the panel and back to the POD longitudinal provider every 60-90 days as decided by the RMD, A-RMD and POD leaders.
• Act as the lead clinician for a majority of the markets D acuity patients across all PODS. Work with HSD and Clinical Supervisors to properly identify D patients who need to have a higher acuity and work with POD leaders to accept higher acuity patients as a D patient. Constantly re-assess the panel to assure proper acuity designation and provides direct or virtual visits as allowed and supervise other Landmark clinical staff (FT, PT and PD) to make visits to provide medical care and education and accurately capture HCC diagnosis and close quality gaps.
• Assist in the development of, documentation, implementation, and interpretation of local medical policies and procedures.
• At the direction of the RMD assists and as needed leads the Interdisciplinary Care Team Meetings (IDT)
• At the direction of the RMD, oversees provider education, in-service training and provider orientation.
• Participates in Medical Director Conferences.
• Remain current in the knowledge of geriatrics, utilization management, quality management, managed care principals and new clinical developments and technologies.
• At the direction of the RMD interact with local attending physicians on application of the Landmark Health model and issues regarding medical practice.

• Assist in supporting the program within the community and assist in the development of local business opportunities for furthering the cause of the program.
• At the direction of the RMD assist in resolving conflicts between physicians and among physicians, members, and Landmark Health personnel.
• Meet/confer periodically via telephone or in person, with the Program Director, VP of Medical Services and other Landmark Health management regarding local issues including patient care plans and authorizations for service.
• Assist in providing Primary Care Physician Services to members in the event that the member’s PCP is unavailable.
• Takes an active role in reviewing and discussing all items pertaining to Utilization Management.
• Assists in identifying requests that require additional review by specialist in a particular field, and assists in establishing a review process with these specialists whenever necessary.
• Supports the Health Services staff in carrying out all UM activities.
• The Medical Director is responsible for oversight of the Utilization Management process. This includes, but is not limited to the following:
  • Referral request determinations
  • Medical Necessity Denial of requests (with consultation with a specialist as needed)
  • Acting as Chairperson of the Utilization Management Committee and the Quality Improvement Committee (if unable to attend, then Medical Director will arrange for his/her “designee” to perform this responsibility
  • Review of policy and procedures
  • Direct communication with individual providers regarding UM decisions
• At the direction of the RMD delegates direct intervention and decision-making regarding the approval and authorization of medical care and services to the appointed POD Leaders as needed within the structure of the established decision-making processes in support of eliminating potential conflict of interest.
• Participates in the continuous assessment and improvement of the quality of care provided to members through Quality Improvement activities.
• Participates in the surveillance of provider performance in conjunction with the Quality Improvement activities.
• Assists in the development, implementation, and evaluation of the Quality Improvement Program.
• At the direction of the RMD participates in the resolution of medically related grievances.
• Participates in provider recruitment activities related to the areas of network expansion, key to identifying additional providers/specialists needed for the network based on target population needs including providers and facilities in target population medical, mental health specialty services across all markets.
• At the direction of the RMD reviews and makes recommendations to the Credentialing Committee regarding the appointment and re-appointment of panel providers.
• Participates actively in the management of provider's contract status within the provider panel to ensure the delivery of quality based health care while supporting the protections of the provider's rights as well as Landmark Health’s obligations for oversight and reporting.
• Participates actively in all Peer Review activities.

EDUCATION AND EXPERIENCE

• Medical Doctor currently licensed to practice without restriction in the state of practice, and has met or exceeded all the credentialing requirements of a provider within the provider panel.
• Current in the knowledge of geriatrics, utilization management, quality management, managed care principals and new clinical developments and technologies.
• Have significant experience in leading teams of physicians and mid-level providers in delivering high quality, cost effective care.
• Experience in recruiting and hiring medical talent along with continuous supervision of the medical care delivered.
• Ability to analyze staffing needs sufficient to care for the patient panel.
• Experience in coaching members of the health care team to provide excellent care or, if needed, determine deficiencies in care and formulate a plan for improvement.