Associate Medical Director - Select Health, Rheumatology

Essential Functions

• Coverage & Benefits determinations: Act as the first level of reviews and appeals for panel providers or members' concerns regarding coverage/benefits issues or quality of care.  
• Utilization Management: Assist in the development and review of Utilization Management screening criteria & policies used in the preauthorization process. Participate in the yearly guideline review process. Participate in ongoing evaluation of the UM process. 
• Participate in a physician specialty panel to assist in peer review of cases and specified turnaround times by accreditation or licensing bodies. 
• Education: Provide clinical education to members of the UM/CM and HCS staff as necessary to perform their function. 
• Preauthorizations and appeals: Review preauthorization requests which fail to pass criteria as applied by staff and document those utilization and case management decisions appropriately in the care management system. 
• Committees: Represent SelectHealth on committees as assigned by the Medical Director. 
• Delivery Improvement: Serve as a resource for the SelectHealth Medical Director in recommending ways to improve health services delivery and reduce medical expenses without compromising quality of care. Constantly stress and strive for cost-effectiveness on the part of physicians and ancillary health care providers. 
• Certification Requirements: Assist and support Health Care Services departments as needed in maintaining NCQA, HEDIS, and CAHPS certification, and other contractual requirements such as Medicare, Medicaid, CHIP, exchange plans and FEHB compliance. 
• Medical Policy: In cooperation with Medical Director writes and updates medical policies. 
• Interacts with the delivery system including clinical programs, individual physicians and clinics to align care process models and clinical practice to evidence based standards. 

Skills

• Leadership
• Performance Metrics
• Results-Oriented
• Communication
• Problem Solving
• Taking Initiative
• Analytical Thinking
• Accountability
• Collaboration
• Professional Etiquette

Qualifications 

Minimum Qualifications 

• Medical Doctor or Doctor of Osteopathic Medicine degree with Board Certification in specialty. Degree must be obtained through an accredited institution. Education is verified.
• Requires current MD or DO licensure within the State of Utah, Idaho, Nevada or Colorado 
• Five years of experience in clinical practice. 
• Experience in a role requiring effective verbal, written, and interpersonal communication skills.

Preferred Qualifications 

• Training in clinical quality improvement.
• Prior experience with Intermountain Health.
• Experience working in an integrated healthcare system.
• Primary care specialty.
• Knowledge of managed care products and processes as well as the impact of managed care on the market and cost of health care.
• Knowledge of the NCQA accreditation standards and process.
• Understanding of health care delivery system as it relates to government programs and agencies.