Veterans, Reservists, Guardsmen and military family members are encouraged to apply!!

We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only)

Job Summary

Oversees and participates in clinical quality reviews, peer review, and provider interactions. Works closely with and oversees clinical staff reviewing potential quality issues and appropriateness of care. Develops provider and system-based corrective action plans as needed. Chairs and coordinates quality and other committee meetings as assigned. Documents reviews of clinical quality and appropriateness of care in the medical management system. Collaborates with VA, network providers, and TriWest staff to assure timely, appropriate and high quality care. Uses data to facilitate and optimize the delivery of health care services. Interacts directly with beneficiaries, as indicated, to assure a high level of satisfacti

Education & Experience

Required:

MD or DO degree obtained from an institution accredited by the Liaison Committee on Medical Education and listed in Association of American Medical Colleges Board Certified by a recognized MD or DO specialty board or proven training to meet board eligibility requirements Current unrestricted license to practice medicine in a state or territory of the United States 5+ years' medical practice experience

Preferred:

TRICARE, Veterans Affairs, or other government health plan experience Advanced management degree (MPA, MBA, MHA, MPH) 2+ years' Managed Care experience

Key Responsibilities

Provides program guidance and clinical oversight for Medical Management programs. Engages in peer to peer discussions with network providers and others. Reviews potential quality issues for corrective action. Reviews member cases for appropriateness of care. Participates in internal, external, and joint quality and safety meetings. Provides clinical consultation to staff, as needed, especially RN and other nursing staff. Provides oversight for clinical decisions impacting beneficiaries. Possesses knowledge of medical practice standards and conducts research, as needed, on new technologies and treatments.

Competencies

Coaching / Training / Mentoring: Actively fosters desired business outcomes through ongoing constructive feedback to others.

Communication / People Skills: Collaborates with and Influences others in both positive and negative circumstances. Adapt to different personalities and behavioral styles. Listens critically.

Computer Literacy: Uses computer hardware and software to effectively research, analyze, and document critical functions.

Coping / Flexibility: Understands and commits to goals and embraces the ideas of others to achieve success.

Independent Thinking / Self-Initiative: Thinks critically with ability to focus on things which matter most to achieving outcomes. Exhibits commitment to tasks to achieve key outcomes without direction. Creatively finds solutions to problems and obtains necessary resources to solve them.

Team-Building / Team Player: Influences the actions and opinions of others in a positive manner. Accepts feedback and incorporates it into actions. Builds group commitment.

Technical Skills: Ability to work in a matrix environment. Proficiency in Microsoft Office applications. Comprehensive knowledge of and ability to participate in and oversee: Case Management and Disease Management Clinical Quality and Continuous Quality Improvement Utilization Management, health care cost containment, and Managed Care practices URAC Standards and process and other accreditation standards as needed HIPAA regulations and requirements

Working Conditions

Working Conditions:

Regular daytime hours with availability to work additional non-regular hours as needed Standard office environment, with limited to mode ate travel Extensive computer work with prolonged sitting Security clearance may be required

Company Overview