Medical Director

Member Engagement Columbus, Ohio


Description

Title

Medical Director

Location

Quantum Health Headquarters, Columbus, (Dublin), Ohio

FLSA Status

Exempt

Reports To

Chief Medical Officer

 

 

SUMMARY

At Quantum Health, the leader in healthcare navigation, we are privileged and humbled to serve an amazing group of clients and members.  As our relationships flourish and our business expands, we find ourselves in the fortunate position of adding a Medical Director to our incredible team.  This physician will possess relevant experience within the virtual healthcare space.  This experience may be with a traditional/non-traditional carrier or another administrative healthcare service provider.  In addition, they will possess the unique combination of strong analytical skills, collaboration, responsiveness, diligence and a passion for both written and verbal communications.

In this brand-new role, the successful candidate will support the award-winning culture, Columbus Best Places to Work for the past fourteen years, as a hands-on, roll-up-your-sleeves, solutions-oriented medical professional.  This is not a lofty, theoretical role.  The ideal candidate will find themselves highly engaged focusing their attention on the front line while partnering with our clinical team to drive the best possible outcomes for every member.

 

ESSENTIAL RESPONSIBILITIES

 

% of Time Spent

Essential Tasks/Duties/Responsibilities

60%

Serves as a key clinical resource for staff. Establishes criteria and protocols for standard medical treatment inquiries and renders determinations on requests for healthcare services and/or treatment when one of the following occur:

·         There are no established criteria related to the request

·         There is a lack of information and the nurse is not able to assess against the established criteria

·         The request is complex or controversial in nature

·         The request does not meet criteria for approval when reviewed against established criteria

 

Conducts daily review of individual cases and has necessary case level conversations as

requested.  This includes prior authorizations and denial decisions for cases that do not meet established evidence-based criteria

 

Provides clear and concise documented medical review determinations and support on requested reviews within the established time frames

 

Provides clinical and nurse consultations

 

Identifies opportunities to implement best practices approaches and introduce innovations to provide improved outcomes

 

 

20%

Offers peer-to-peer discussions regarding determinations as necessary

 

Serves as a medical liaison to physicians, hospitals and insurance carriers

 

Provides determination on appeals for cases where they did not make the initial determination

 

Utilizes data resources and tools that helps our team provide personalized care to our clients

 

Evaluates and interprets data.  Identifies areas for improvement with a focus on interventions to improve client outcomes

 

20%

Provides clinical expertise in support of medical management programs through participation in clinical team activities

 

Provides clinical expertise to Sales and Client Engagement

 

Develops and mentors clinical professionals

 

Conducts clinical education sessions as necessary

 

 

 QUALIFICATIONS / REQUIREMENTS:

 

Skills and Qualifications:

  • Previous experience in the virtual healthcare employee benefits space, (Traditional/non-traditional or other administrative healthcare provider)
  • Physician clinical review experience
  • Extremely strong written and verbal communication skills and the ability to deliver in an agreed-upon time frame
  • Team oriented and collaborative ethos
  • Diligent and responsive approach
  • Knowledge of health care delivery system
  • Knowledge of utilization management and InterQual criteria

 

Education:

  • MD or DO from an accredited university

 

Experience:

  • Five+ years of progressively relate work experience

 

Certification and Licensure:

  • Active and current medical license without encumbrances
  • Board certification in a recognized specialty

 

Physical Requirements:

  • Ability to sit or stand for long periods of time while completing work on a computer

 

Environment:

  • Office

 

Comments:

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform job-related tasks other than those specifically presented in this description.