Corporate Medical Director (Part-Time)
At Claritev, we pride ourselves on being a dynamic team of innovative professionals. Our purpose is simple - we strive to bend the cost curve in healthcare for all. Our dedication to service excellence extends to all our stakeholders – internal and external - driving us to consistently exceed expectations. We are intentionally bold, we foster innovation, we nurture accountability, we champion diversity, and empower each other to illuminate our collective potential.
Be part of our amazing transformational journey as we optimize the opportunity towards becoming a leading technology, data, and innovation voice in healthcare. Onward and Upward!!!
JOB SUMMARY
This position assists with the development and enforcement of the company's Credentialing Program to include utilizing relevant clinical knowledge ensuring a high-quality provider network. The incumbent oversees credentialing and re-credentialing of network participants, monitoring state and federal sanctions, and assures the achievement of quality and outcome measures. Leads Credentialing Committee with other clinical and non-clinical administrative staff in investigating issues related to quality of care, utilization of services and appropriate billing. Monitors overall Credentialing program to ensure it maintains compliance with State, Federal and Network Accreditation to include NCQA. Represents the Company to insurance carriers, network providers, members, and the managed care community.
DUTIES
- Comply and assure compliance with all relevant governmental regulations, accreditation standards and company policies including NCQA.
2. Ensure timely, smooth and effective day-to-day policy, assessment activities and accomplishment of business objectives. Collaborate on special projects and task forces on a company-wide basis to include building specialty crosswalks for network adequacy filings.
3. Ensures all relevant clinical facts, documentation, and materials are prepared for the weekly Credentialing Committee. Responsible for leading discussions and providing input into leading to a decision regarding network participation.
4. Primary signatory on Credentialing Committee file approvals and network participation letters.
5. Investigates issues related to quality-of-care complaints, potential fraud, waste or abuse of all providers received by Corporate Quality Management and recommends a course of action. When necessary, findings are presented to the Credentials Committee for determination relative to network participation.
6. Coordinate with out of network services Medical Director regarding potential Fraud, Waste or Abuse on all claims to include providing recommendations regarding out of network claim pricing decisions.
7. Consult with the Assistant Vice President, Operations regarding business plans, strategic planning activities and service implementation providing relevant clinical guidance as required.
8. Oversee clinical quality management programs as required.
9. Monitor specific quality indices and acts or recommends action based on significant variances.
10. Provides clinical oversight regarding the credentialing and recredentialing of network providers and facilities. Works cooperatively and collaboratively with all corporate staff and all network development staff in the development of a high-quality provider network.
11. Represents physicians and medical perspective as part of the leadership team. The team includes regional leadership for the service organization, network development, sales support, and quality improvement.
12. Represents the Company as appropriate, to external contacts such as contracted providers, attorneys, clients, accrediting bodies, in public forums including insurance carrier presentations, network provider presentations, the managed care community and other interactions external to the organization.
13. Select, develop, and evaluate staff to ensure the efficient operation of department.
14. Ensure systematic data-oriented efforts to improve consumer and/or client services. One hundred percent 100% of this job is related (directly or indirectly) to QM activities.
15. Collaborate, coordinate, and communicate across disciplines and departments.
16. Ensure compliance with HIPAA regulations and requirements.
17. Demonstrate commitment to the Company's core values.
18. Please note due to the exposure of PHI sensitive data -- this role is considered to be a High-Risk Role.
19. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.
JOB SCOPE:
The incumbent works under minimal direction, may lead and motivate staff, and uses independent judgment to identify issues, trends and problems. Recommends action plans, evaluates and presents results. Work is clinical in nature, varied and complex requiring the incumbent to use a broad range of knowledge gained through extensive experience. Quality Management (QM): This job has approximately 100% of its responsibilities that are either directly or indirectly dedicated to QM functions.