Job Description

PRIMARY PURPOSE

Reviews requests for prior authorization and appeals for approval or denial of claims payment based on medical necessity. Oversees medical coordination required for effective utilization and quality management of the health plan network. Supports the clinical activities of PCHP Utilization Management, Quality Management, Clinical Policy, Technology Assessment, Credentialing, Population Health and Fraud, Waste and Abuse Functions to assure comprehensive, high quality health care to plan members in accordance with managed care and PCHP policies. Monitors clinical care needed to produce optimal health outcomes and cost-effective care.

MINIMUM SPECIFICATIONS

Education

• Must have successfully completed an Accreditation Council for Graduate Medical Education (ACGME) or American Medical Association (AMA) approved residency in an appropriate specialty to the PCHP population.

Experience

• At least five years of clinical practice experience in a specialty relevant to the care of PCHP members.
• At least three years of experience in the care of populations relevant to the PCHP population or managed care.
• At least of three years experience in the care of populations relevant to the PCHP population or managed care.
• Substantial experience and expertise in the development of medical policies, procedures and programs required.
• Demonstrated success implementing utilization and quality improvement strategies /techniques and experience with physician behavior modification required.
• Qualifications to perform clinical oversight for the services provided by the health plan to include but not limited to education, training or professional experience in medical or clinical practice preferred.
• Past participation in a managed care UM committee preferred.

Certification/Registration/Licensure

• Must be currently licensed for the practice of medicine in the State of Texas.
• Must meet and maintain licensing and registration requirements as required by the State of Texas for Managed Care Medical Directors.

Skills or Special Abilities

• Must be philosophically oriented to the managed care concept of health delivery.
• Must have a working knowledge of managed care principles.
• Must demonstrate strong leadership, organizational, interpersonal, and verbal skills including demonstrated ability to work efficiently and communicate with executive management, physicians groups, community and provider organizations, and persons of diverse socioeconomic backgrounds.
• Must be able to demonstrate a working knowledge of Texas Medicaid Regulations and their interpretation.
• Must demonstrate effective supervisory, administrative and management skills including computer literacy.
• Must be able to demonstrate patient centered/patient valued behaviors.
• Must understand and demonstrate knowledge of principles of care coordination and collaboration, population health and social determinants of health, clinical evaluation of evidence based care and value based purchasing.
• Must be familiar with the role of pharmacy and behavioral health in managing health care.
• Ability to create, review and interpret treatment plans.
• Ability to adapt to changing priorities.
• Demonstrated ability to deal with confidential information.
• Demonstrated negotiation skills.
• Ability to remain calm under pressure.
• Ability to apply medical knowledge and principles to business challenges in order to achieve significant member, business, and quality outcomes.
• Ability to be detail-oriented and have a hands-on approach.

Responsibilities

• Reviews prior authorization and appeals request for approval or denial of claims payment based on medical necessity.
• Performs peer to peer calls as necessary to support the utilization management process.
• Provides clinical oversight for utilization management, disease management and quality management activities as assigned by the PCHP Chief Medical Officer or Sr. Medical Director including participation in development of medical policies and procedures for coverage and authorization and clinical standards and guidelines based on evidence-based medicine.
• Analyzes data to establish health care provider profiles and define acceptability of physician performance, conducts review of provider applications and qualifications, and participates in the review process of providers who fail to meet required standards, site and medical record reviews, as appropriate, to ensure adherence to managed care and PCHP policies.
• Assists the Sr. Medical Director and the Pharmacy Director of PCHP in overseeing and administering the pharmacy benefit for PCHP members including coordination of care between the Medical and Pharmacy benefits.
• Assists the Sr. Medical Director in oversight, evaluation, and administration of the clinical aspects of PCHP fraud, waste and abuse programs.
• Participates in development, implementation, and monitoring of annual goals and objectives for PCHP that support the mission and objectives of Parkland.
• Assists in identifying member and provider needs for education and health promotion. Participates in assessment of existing education programs offered to providers, developing and evaluating such programs, as required, to ensure that managed care service area and PCHP needs are appropriately served.
• As assigned by the Chief Medical Officer or Senior Medical Director assists in representing PCHP on clinical activities with relevant State and local bodies such as the Texas Department of Insurance, Texas Health and Human Services Commission, and Texas Medical Association.
• Participates in identification and analysis of process improvement of jobs design, work processes, and work flows for the clinical area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of the managed care delivery system and PCHP.
• As assigned by the Chief Medical Officer or Sr. Medical Director, serves as chairperson or member of managed care committees, and participates on various community and interdisciplinary committees.

Job Accountabilities

• Identifies and analyzes the design of jobs, work processes, work flows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of the department and Parkland.
• Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
• Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.
• Develops and monitors annual budgets that ensure the department has the necessary funds to carry out the goals and objectives that have been established for the department.
• Develops, implements, monitors, and revises annual goals and objectives for the department that support the missions and objectives of Parkland.
• Selects, trains, schedules, motivates, supervises, and evaluates employees making recommendations for disciplinary actions up to and including termination, to ensure maximum utilization of individual and group capabilities. Ensures that assigned employees receive opportunities to further their knowledge.