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Essential Job Functions
Assists in development and maintaining an efficient UM program to meet the needs of the health plan members and commensurate with company values.
Educates primary care physicians regarding systems, structures, processes and outcomes necessary for assurance of regulatory compliance related to market activities.
Develops strategies for improving all aspects of market performance including RAPS, membership, and medical management.
Participates in case review and medical necessity determination.
Conducts post service reviews issued for medical necessity and benefits determination coding.
Analyzes aggregate data and reports to primary care physician.
Serves as the liaison between physicians and health plan Medical Directors.
Supervises the functions of Care Coordination.
Assesses the effectiveness of the specialty network to ensure members have access to multi-specialties within their demographic area.
Represents the providers as an influence to the credentialing committee.
Reviews policies and procedures of credentialing department and offers guidance for revision and implementation of process.
Educates primary care network and assists in problem resolution.
Assists in development of medical management protocols.
Performs analysis of utilization data and suggests/implements corrective action plans with network physicians.
Performs all other related duties as assigned.
Oversees and insures physician compliance with UM plan.
Evaluates performance of physicians in regards to established goals and objectives of the company.
Performs all duties with physicians and medical group staff in a professional and responsible manner.
Responds to physicians in a prompt, pleasant and professional manner.
Respects physician, patient, and organizational confidentiality.
Educates medical groups regarding UM policies, procedures and government-mandated regulations.
Provides quality assurance and education of current medical technologies, review criteria, accepted practice of medicine guidelines, and UM policies and procedures with counsel when criterion are not met.
Personal and Physician Development
Strives to personally expand working knowledge of all aspects of the UM department.
An active participant in physician meetings.
Orients new physicians to ensure understanding of company policy and resources available for physician support.
Encourages teamwork and cooperation with medical group staffs in order to prepare for cross training and float positions.
Assists in the growth and development of subordinates by sharing special knowledge with others and promotes continued education classes.
Attends continuing education classes to keep abreast of medical advancements and innovative practice guidelines.
WellMed is a healthcare delivery system serving more than 90,000 patients, primarily Medicare eligible seniors, in Texas and Florida through primary care clinics, multi-specialty clinics, and contracted medical management services. Headquartered in San Antonio, Texas, WellMed is an industry leader in medical risk management, highly effective disease management and chronic care programs, healthcare delivery services and more.
Our focus and mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. We are innovators in preventative healthcare, striving to change the face of healthcare delivery for seniors. Our providers and support staff are selected for their dedication to the senior population and focus on preventative, proactive patient care.
WellMed is now part of the OptumHealth division under the greater UnitedHealth Group umbrella.