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State Medical Director

Execu|Search Type Full time Posted 10/24/2013
Salary Negotiable Starts 4/16/2014
NY - New York (All) - Manhattan Referral - n/a -    
State Medical Director
Location: Manhattan, NY
Experience: 2. year(s)
Job Type: Full-Time
Job ID: J121133

About the Opportunity

A healthcare company in New York City is now seeking a State Medical Director. The State Medical Director (SMD) is responsible for ensuring that medical protocols and practice guidelines support and promote the programs of the company in respective states. He or she also conducts reviews of clinical cases and oversees benefit determinations. 

Company Description

Healthcare Company

Job Description

Essential functions and responsibilities include:

  • Leadership of State clinical policy and program development and of the initiation of clinical strategies to improve quality and deliver cost effective care
  • Management of the development of State and corporate clinical standards, best practice guidelines, and clinical policy to improve care
  • Management of the development and approval of clinical and contractual outcomes included in provider and vendor contracts or agreements
  • Clinical Oversight and support of Clinical and Client Services to ensure optimal quality of care
  • Oversight of prior authorization, utilization management, and benefit administration
  • Collaborates with providers and external groups/associations on clinical policy relevant to the company Model of Care and member/ provider communities
  • Collaborates with theCMOand Chief Compliance Officer to ensure the compliance of the company including that of providers
  • Collaborates with Network Managers to assist in the establishment of a network
  • Clinical leadership and consultation to State company staff through ongoing case reviews
  • Assists with benefit determinations, review of complaints/grievances and appeals as necessary
Required Skills
  • Board certification in Family Practice or Internal Medicine
  • Knowledge and experience in managed care and coordinated care models 
  • At least two years' clinical experience caring for a geriatric population
  • At least two years of experience in medical management/leadership
  • Experience with Medicaid/Medicare programs/populations
  • Knowledge of federal and state regulations, guidelines and standards
  • Excellent communication, management and leadership skills
  • Knowledge of accrediting organizations, such asNCQA
  • Knowledge of medical criteria sets and benefit categories and structures,HEDISand other quality measures$
Desired Skills
  • Certification in Geriatrics