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Associate Medical Director or Medical Director

Company: Cambia Health Solutions, Inc.
Location: Washington
Posted on: July 30, 2022

Job Description:

Associate Medical Director or Medical Director Oregon, Washington, Utah or Idaho Our Medical Directors provide clinical leadership and support to clinical teams to ensure our members receive quality, cost effective care yielding optimal outcomes. This role will primarily provide UM services in areas requiring prior authorization for inpatient and outpatient medical care. The role may also include: Medical policy support, CM support, program development and other medical and utilization management support, and other clinical duties as assigned. General Functions and Outcomes Conducts peer clinical review for medical necessity on utilization management authorization requests. Provides clinical input on case management reviews working closely with the CM clinical staff. Responsible for discussing review determinations with providers who request peer-to-peer conversations. Participates in various efforts to provide clinical input on medical policy reviews and development and may participate with others who develop programs impacting clinical interventions, utilization management and case management. Analyzes and uses data to guide the development and implementation of health care interventions that improve value to the member and employer. Advises Health Care Services Leaders on related key performance metrics and the effectiveness of various efforts, initiatives, policies and procedures. Identifies and communicates new opportunities in utilization management, provider contracting or other areas that would enhance outcomes and the reputation of the organization. Provides clinical expertise and coordinates between internal clinical programs and providers of care to improve the quality and cost of care delivered to health plan members. Ensures ethical decision making in compliance with contractual arrangements, regulations and legislation. Supports internal communication or training that ensures service is provided to members and providers by a well-trained staff. Promotes provider understanding of utilization management and quality improvement policies, procedures and standards. Provides guidance and oversight for clinical operational and clinical decision-making aspects of the program. Has periodic consultation with practitioners in the field and ensures that the organization has qualified clinicians accountable for decisions affecting consumers. May manage staff including hiring, performance management, development and retention. May participate in health plan credentialing operations and clinical aspects of the credentialing program and provider services support. Minimum Requirements Demonstrated competency working with hospitals, provider groups or integrated delivery systems to effectively manage patient care to improve outcomes. Strong communication and facilitation skills with internal staff and external stakeholders, including the ability to resolve issues and seek optimal outcomes. Proven ability to develop and maintain positive working relationships with community and provider partners. ---Ability to implement required aspects of the health insurance industry, state and federal regulations, provider reimbursement methods and evolving accountable care and payment models. General business acumen including understanding of market dynamics, financial/budget management, data analysis and decision making. Strong orientation to the application of data in managing health and quality. Proven ability to develop creative strategies to accomplish goals and objectives, plan and execute complex projects and programs and drive results across internal teams and/or external partners. Demonstrated ability to effectively lead and engage in a constructive manner with others. Normally to be proficient in the competencies listed above: Associate Medical Director would have a MD or DO degree, at least 3 years clinical experience, or equivalent combination of education and experience. Medical Director would have a MD or DO degree, at least 5 years clinical experience, plus at least 2 years medical utilization management and/or case management experience (prefer health insurance experience and additional MHA or MBA training), or an equivalent combination of education and experience. Required Licenses, Certifications, Registration, Etc. Licensed Physician with an MD or DO degree. Active, unrestricted license to practice medicine in one or more states or territories of the United States. Board Certification required. Qualification by training and experience to render clinical opinions about medical conditions, procedures and treatments under review. Work Environment Work is performed primarily in a remote location. Periodic travel to a different office location, provider office, or other meeting location. May be required to work outside normal working hours. Must be located in a state or territory of the United States when conducting a peer clinical review. Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association. If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions. This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required. If you need accommodation for any part of the application process because of a medical condition or disability, please email Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our Careers site.

Keywords: Cambia Health Solutions, Inc., Saint George , Associate Medical Director or Medical Director, Executive , Washington, Utah

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