Senior Medical Director, New Hampshire

Position Purpose

Assist the Vice President of Medical Affairs to direct and coordinate the medical affairs functions for the business unit. Oversee the denials and appeals department. May manage other medical directors. Assume VPMA responsibility in absence of VPMA.

Key Details

Serve as Clinical Executive leader representing the health plan both internally and externally; specifically serving in the role as physician executive leader with NH Department of Health and Human Services on all clinical escalations, state fair hearings and health plan advocacy. The Senior Medical Director must be located in New Hampshire or willing to relocate.

• Provide medical leadership for all utilization management, pharmacy, case management, disease management, cost containment, and medical quality improvement activities.
• Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
• Support the effective implementation of performance improvement initiatives for capitated providers.
• Assist VPMA in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Assist the VPMA in the functioning of the physician committees including committee structure, processes, and membership.
• Oversee the activities of physician advisors and other medical directors.
• Utilize the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
• Participate in provider network development and new market expansion as appropriate.
• Participate in provider profiling initiatives.
• Assist in the development and implementation of physician education with respect to clinical issues and polici