PRIMARY PURPOSE

Reviews requests for prior authorization and appeals for approval or denial of claims payment based on medical necessity. Oversees medical coordination required for effective utilization and quality management of the health plan network. Supports the clinical activities of PCHP Utilization Management, Quality Management, Clinical Policy, Technology Assessment, Credentialing, Population Health and Fraud, Waste and Abuse Functions to assure comprehensive, high quality health care to plan members in accordance with managed care and PCHP policies. Monitors clinical care needed to produce optimal health outcomes and cost-effective care.

MINIMUM SPECIFICATIONS

Education

- Must have successfully completed an Accreditation Council for Graduate Medical Education (ACGME) or American Medical Association (AMA) approved residency in an appropriate specialty to the PCHP population. Experience

- At least five years of clinical practice experience in a specialty relevant to the care of PCHP members.

- At least three years of experience in the care of populations relevant to the PCHP population or managed care.

- Substantial experience and expertise in the development of medical policies, procedures and programs required.

- Demonstrated success implementing utilization and quality improvement strategies /techniques and experience with physician behavior modification required. - Qualifications to perform clinical oversight for the services provided by the health plan to include but not limited to education, training or professional experience in medical or clinical practice preferred.

- Past participation in a managed care UM committee preferred.

Responsibilities

1. Reviews prior authorization and appeals request for approval or denial of claims payment based on medical necessity.

2. Performs peer to peer calls as necessary to support the utilization management process.

3. Provides clinical oversight for utilization management, disease management and quality management activities as assigned by the PCHP Chief Medical Officer or Sr. Medical Director including participation in development of medical policies and procedures for coverage and authorization and clinical standards and guidelines based on evidence-based medicine.

4. Analyzes data to establish health care provider profiles and define acceptability of physician performance, conducts review of provider applications and qualifications, and participates in the review process of providers who fail to meet required standards, site and medical record reviews, as appropriate, to ensure adherence to managed care and PCHP policies.

5. Assists the Sr. Medical Director and the Pharmacy Director of PCHP in overseeing and administering the pharmacy benefit for PCHP members including coordination of care between the Medical and Pharmacy benefits.

6. Assists the Sr. Medical Director in oversight, evaluation, and administration of the clinical aspects of PCHP fraud, waste and abuse programs.

7. Participates in development, implementation, and monitoring of annual goals and objectives for PCHP that support the mission and objectives of Parkland.

8. Assists in identifying member and provider needs for education and health promotion. Participates in assessment of existing education programs offered to providers, developing and evaluating such programs, as required, to ensure that managed care service area and PCHP needs are appropriately served.

9. As assigned by the Chief Medical Officer or Senior Medical Director assists in representing PCHP on clinical activities with relevant State and local bodies such as the Texas Department of Insurance, Texas Health and Human Services Commission, and Texas Medical Association.

10. Participates in identification and analysis of process improvement of jobs design, work processes, and work flows for the clinical area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of the managed care delivery system and PCHP.

11. As assigned by the Chief Medical Officer or Sr. Medical Director, serves as chairperson or member of managed care committees, and participates on various community and interdisciplinary committees.