Medical Director PRN

Position Purpose: Assist the CMO to direct and coordinate the physician component of the utilization management functions for the health plan business units. Key Details: Must be Board Certified Physician with an active Indiana MD or DO state license. The ideal candidate will reside in Indiana and have utilization management experience. This role is roughly 20 hours per week with Thursdays/Fridays being the highest priority. Provides medical leadership for utilization management activities and medical review activities pertaining to utilization review, quality assurance, medical review of complex, and controversial or experimental medical services such as transplants utilizing the services of consultants Performs case reviews and appeals for all health plans. Assists CMO in planning, establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Reviews claims involving complex, controversial, or unusual