Medical Director

<strong>Working at Advantasure is more than a job &mdash; you&rsquo;re part of a team that is becoming the country&rsquo;s leading healthcare solutions provider.<br /></strong><br /><strong>A career at Advantasure means you&rsquo;ll be part of one of the most dynamic, diversified and innovative healthcare companies in the nation. You&rsquo;ll be helping our clients make their members healthier &mdash; and our communities a better place to call home.</strong>

Detroit, USA


<p class="p1"><strong>At Advantasure, we partner with healthcare clients to simplify their operations and accelerate their business success. Powered by our broad expertise and a comprehensive suite of product and service solutions, we help health plans effectively navigate the complexity of healthcare.</strong></p>

keywords: summary,job description,work environment,review,documentation,operations support,provider education,performance,other duties,education,experience,proficiency,knowledge,communication,skills

Senior Director

Competitive Compensation and Benefits Package

Overview: <br />This role provides day-to-day clinical oversight and support to a multi-department health insurance services organization. Assists the Health Management, Clinical Operations, Risk Adjustment and Quality organizations to achieve performance metrics, regulatory measures and business goals.&nbsp;This role may also include an advisory and educational function to external providers on behalf of the organization&rsquo;s Medicare risk adjustment clients.&nbsp;Supports the design of programs and processes which improve CMS and other regulatory measures, patient outcomes and drive down cost of care for our clients and their members. Supports executive leadership team in enterprise efforts related to the development and implementation of business goals, programs, products and strategic initiatives. &nbsp;<br /><br /> <p><strong>WORKING CONDITIONS:</strong></p> <p>Work is performed in an office setting with no unusual hazards. Requires transporting, pushing, pulling, and maneuvering items weighing up to 25 pounds. Travel required.</p>
Responsibilities: <br /> <p><strong>Utilization Management:</strong></p> <ul> <li>Performs secondary reviews on services requiring prior authorization which do not meet medical necessity criteria and those requested by out of network providers</li> <li>Conducts peer-to-peer discussions with providers requesting to add clinical context to reverse a clinical decision</li> <li>Renders decisions to uphold or overturn denials once all clinical information is gathered and reviewed</li> <li>Performs and documents decisions and discussions in accordance with applicable regulatory standards</li> </ul> <br /> <p><strong>Clinical Reviews for Appeals and Grievances:</strong></p> <ul> <li><a target="_blank">Reviews member requests for organizational determinations and renders decisions on medical necessity</a></li> <li>Performs clinical reviews and renders decisions on level 1 and level 2 provider appeals. Provides clinical support to all aspects of the CMS appeal and grievance process</li> <li>Reviews unfavorable decisions made by the IRE and assists with building a case to reverse these decisions</li> </ul> <br /> <p><strong>Clinical Operations Support:</strong></p> <ul> <li>Brings the provider&rsquo;s perspective into the development of programs, products, clinical platforms and materials across the organization</li> <li>Supports internal and external audits requiring clinical input</li> <li>Assists the risk adjustment and quality teams to expand their clinical knowledge to improve their understanding of clinical documentation and facilitate their communication with providers in the field</li> <li>Supports CMS bid development, Stars Strategy</li> </ul> <br /> <p><strong>Provider Education &ndash; Risk Adjustment:</strong></p> <ul> <li>Delivers education to client&rsquo;s providers relative to Medicare&rsquo;s risk adjustment model</li> <li>Provides education on documentation and coding to support the organization&rsquo;s risk adjustment programs</li> <li>Provides education to improve providers&rsquo; performance in meeting quality measures as they pertain to Medicare&rsquo;s Stars rating</li> <li>Holds targeted education sessions based on observed documentation trends and market-specific needs</li> <li>Develops and continuously updates educational materials, digital and print, including tip sheets, slide decks and webinars</li> </ul> <br /> <p><strong>CDI Alert Review:</strong></p> <ul> <li>Performs daily review of CDI alerts returned by providers in the PEC program against documentation in the medical record</li> <li>Creates queries requesting amended or additional documentation when needed</li> <li>Captures and enters risk-adjusting diagnosis codes in the MRR platform</li> <li>Identifies and tracks trends in provider documentation and coding and works with PECs to tailor and target provider education based on the specific needs in the market</li> </ul> <p><em><br /></em>This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.</p>
Requirements: <br /> <p><strong>EDUCATION:</strong></p> <ul> <li>Doctor of Medicine Degree (M.D.) or Doctor of Osteopathic Medicine (DO) required.&nbsp;</li> <li>Advanced degree, such as MBA, MHA, MPH, MMM, or a related field preferred.&nbsp;</li> <li>Board Certified in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy preferred.</li> <li>Active, unrestricted State Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) license is required.&nbsp;</li> <li>Continuous learning, as defined by the licensing body to maintain an active license, is required.&nbsp;</li> </ul> <br /> <p><strong>EXPERIENCE:</strong></p> <ul> <li>Ten years of progressively more responsible experience in a healthcare environment is required.</li> <li>Previous health plan or health insurance role is strongly preferred.</li> <li>Demonstrated technical experience that provides the necessary knowledge, skills and abilities.&nbsp;</li> </ul> <br /> <p><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:</strong></p> <ul> <li>Recent and related health plan or health insurance experience, knowledge of activities, practices and terminology of the insurance industry</li> <li>Demonstrated experience with Utilization Management, Care/Disease Management, Risk Adjustment, Risk Revenue, STARS/CAHPS/HEDIS measures, Medical Policy, Appeals &amp; Grievance</li> <li>Demonstrated ability in using data-driven decision making to design programs and processes which improve patient outcomes and drive down cost of care</li> <li>Health care practice experience providing services to Medicare Advantage and Medicaid patients required.</li> <li>Ability to lead initiatives collaboratively across a matrixed enterprise in a fast-paced, growth-oriented environment</li> <li>Excellent analytical, organizational and problem-solving skills</li> <li>Certification in risk adjustment professional coding (CRC) from the American Association of Professional Coders (AAPC) is preferred.&nbsp;</li> <li>Knowledge of documentation opportunities and clinical documentation requirements.&nbsp;&nbsp;&nbsp;</li> <li>Able to conceptualize and develop new ideas and opportunities for improvements, proactively assess the impact of emerging industry, economic &amp; competitive trends</li> <li>Excellent oral and written communication, as well as presentation skills.</li> <li>Ability to anticipate business needs and implement processes and products that support them&nbsp;</li> <li>Ability to interact with others at all levels of the organization, build consensus and drive objectives to completion</li> </ul> <br /><br /><br /> <p>The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.&nbsp;</p> <p>We are an Equal Opportunity Employer. Diversity is valued, and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.</p>