医疗护理管理主任
Medical Director Care Management
医学主任将与团队密切合作，执行各种类型的使用管理（UM）审查，包括但不限于服务前审查、服务后审查、同步审查和申诉。
主要职责：
• 执行各种类型的使用管理（UM）审查，包括但不限于服务前审查、服务后审查、同步审查和申诉
• 与医生提供者进行病例讨论（同行评审）
• 应用健康计划审查层级，根据成员合同、医疗政策、临床指南和其他批准的资源，及时对医疗必要性请求做出决定
• 与案例管理员合作，为需要医生协助的病例提供支持和指导
• 达到与UM审查效率、及时性和审查质量相关的既定指标（合规性和认证）
• 参与持续的评审者间一致性（IRR）审计及其他必要的健康计划审计
• 在需要时，协助护士和其他员工理解适当的使用审查原则，以及福利和政策的解释与应用
• 参与医学和药房政策的制定和审查
• 作为专业领域专家支持组织
• 作为使用管理某一子类别的主要医学主任顾问，例如商业或医疗保险政策
• 执行组织分配的其他职责
职位要求：
• 持有佛罗里达州无限制的医学博士或骨科医学博士执照
• 美国医学专科委员会认证或具备认证资格
• 5年以上临床经验
• 具有在动态、快节奏环境中工作的经验
• 具有独立工作和团队合作的经验
• 出色的口头和书面沟通能力
优先考虑：
• 医生评审或使用管理经验
• 具有初级护理专科医生经验
一般身体需求
久坐工作：偶尔需要施加最多10磅的力量移动物体。如果仅偶尔需要走动，则属于久坐工作。
我们提供的福利：
作为佛罗里达蓝员工，您将在“健康生活、工作愉快、指南健康”的文化中茁壮成长，其中个人健康和团队协作同样重要，以服务于我们的会员和社区。
为支持您的健康，我们提供全面的福利。作为e
查看英文原文
The Medical Director will work closely with the team to perform all types of utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals.
Key Responsibilities:
• Perform all types of utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals
• Discuss cases with physician providers (Peer to Peer)
• Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests
• Collaborate with Case Managers to provide support and guidance on cases needing physician assistance
• Meet any established metrics (compliance and accreditation) related to UM review efficiency, timeliness, and quality of review
• Participate in ongoing Inter-rater reliability (IRR) audits and any other health plan audits as necessary
• As necessary, assist nurses and other staff in understanding the principles behind appropriate utilization review and interpretation and application of benefits and policies
• Participate in the development and review of Medical and Pharmacy policies as assigned
• Support the organization as a subject matter expert
• Perform as lead Medical Director consultant for one sub-category of utilization management, such as commercial or Medicare medical policy
• Perform other duties as assigned and needed by the organization
Position Requirements:
• Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine
• Board Certification or Board eligibility by American Board of Medical Specialties or equivalent
• 5+ years of clinical experience
- Experience working in a dynamic, fast-paced environment
- • Experience working both independently and in a team environment
- • Exceptional verbal and written communication
Preferred:
• Physician reviewer or utilization management experience
• Primary Care Specialty physician experience
General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.
To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:
Medical, dental, vision, life and global travel health insurance;
Income protection benefits: life insurance, short- and long-term disability programs;
Leave programs to support personal circumstances;
Retirement Savings Plan including employer match;
Paid time off, volunteer time off, 10 holidays and 2 well-being days;
Additional voluntary benefits available; and
A comprehensive wellness program
Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.
To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.
Annualized Salary Range: $224,000 - $364,000
Typical Annualized Hiring Range: $224,000 - $280,000
Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.
We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.
Originally posted on Himalayas