JOB REQUIREMENTS: Network Health's success is rooted in its mission to
create healthy and strong Wisconsin communities. Network Health is
seeking an Associate Medical Director. The Associate Medical Director is
responsible for the administration of procedures, protocols, and
standards regarding the efficiency and quality of the health care
delivered to Network Health Plan (NHP) members. Demonstrate commitment
and behavior aligned with the philosophy, mission, values, and vision of
Network Health Appropriately apply all organizational and regulatory
principles, procedures, requirements, regulations, and policies Conduct
oneself in a manner which promotes quality and service excellence for
clients, members, physicians, staff, and visitors and contributes to the
spirit of teamwork within Network Health, Inc. (NHI) Assist the Chief
Medical Officer (CMO) with monitoring availability, appropriateness, and
necessity of care rendered by participating providers and by out-of-plan
providers Participate in the daily operations of the UM program
including but not limited to rendering denial determinations for
services not considered medically necessary or
experimental/investigation/unproven in accordance with regulatory and
quality standards Contribute to the development of quality care
guidelines, internal peer review procedures, and the evaluation of
medical care evaluation studies under the NHP quality assurance
programs. In coordination with the CMO and Directors of Health
Management and QI and Disease Management, share responsibility for the
development and continued evaluation of utilization review and quality
assessment processes Promote positive relationship between NHP and
medical community Serve as liaison between NHP and providers regarding
matters of medical policy and medical administration Serve as
spokesperson for NHP in the medical community and maintain appropriate
contact with professional health care organizations Participate in the
ongoing recruitment of plan physicians Assist in the development of
appropriate medical guidelines and parameters for claims review Assist
in the training of NHP staff on matters relating to medical guidelines
Work closely with Utilization Management team as part of first level
claims review Serve on committees as coordinated with the CMO Assist in
strategic planning targeted towards plan growth initiatives Performs
other duties and responsibilities as assigned * OTHER
EXPERIENCE AND QUALIFICATIONS: Management courses or courses in managed
care preferred Participation in management committees in a practice or
hospital setting required Experience as a medical director preferred
Experience and knowledge of managed care principals, utilization
management, case management, quality, and population health preferred
* APPLICATION INSTRUCTIONS: Apply Online:
https://networkhealth.com/careers