General Pediatric Physician - Physicians Only Apply - Perm - Columbia South Carolina

Company: Nneka Chinyere Anaebonam
Location: Columbia, South Carolina
Posted On: 04/16/2024

A General Pediatric Physician practice is seeking a qualified physician for Columbia, SC. This and other physician jobs brought to you by ExactMD. Medical Doctors Only Apply.

Chief Medical Director
Position
Purpose: Direct and coordinate the medical management, quality improvement and
credentialing functions for the assigned business unit based on, and in support
of the strategic plan, establishing the strategic vision and attendant policies
and procedures.

Serves as clinical advisor to and educator of medical
management staff making sure correct clinical judgment is applied to all
medical management determinations.
Oversees internal medical review guidelines to ensure
clinical integrity and compliance and acts as a resource for staff members
throughout the operation.
Coordinates with other departments, the responses needed to address
regulatory accreditation concerns pertaining to medical management issues
Performs medical review activities pertaining to utilization
review, quality assurance, and medical review of complex, controversial,
or experimental medical services.
Facilitates the achievement of the Medical Management Program
goals through an effective health services delivery system.
Responsible for physician review and oversight of all
potential adverse determinations including pre-certifications/prior
authorizations, concurrent review and appeals/retrospective review.
Responsible for HEDIS improvement and strategy.
Actively participates in the auditing process of medical
management processes and corrective action team projects for medical
management
Achieves utilization, cost management and quality goals.
Participates and advises in the development of corporate
medical policies for UM, pharmacy, and new technology

For Home State Health Plan only --- responsible for the sufficiency and
supervision of the health plan provider network



Directly involved in the CHC-MCO's recruiting and credentialing activities
Familiar with local standards of medical practice and
nationally accepted standards of practice, including those for LTSS and
with most integrated setting requirements under the ADA.
Knowledge of due process procedures for resolving issues
between Network Providers and the CHC-MCO administration, and between
participants and the CHC-MCO, including those related to medical decision
making and utilization review.
Available to review, advise and take action on questionable
hospital admissions, Medically Necessary days and all other medical care
and medical cost issues.
Directly involved in the CHC-MCO's process for prior
authorizing or denying services and is available to interact with
Providers on denied authorizations.
Knowledge of current peer review standards and techniques.
Knowledge of risk management standards.
Directly accountable for all Quality Management and
Utilization Management activities.
Oversees and is accountable for: (a) referrals to the
Department and appropriate agencies for cases involving quality of care
and services that have adverse effects or outcomes; and (b) the processes
for potential Fraud, Waste, and Abuse audit, investigation, review,
sanctioning and referral to the appropriate oversight agencies.


Education/Experience:
Medical Doctor or Doctor of Osteopathy, board certified in a specialty
recognized by the American Board of Medical Specialists. Volunteer patient care
required. Previous experience as Medical Director is preferred. Master---s degree
in Business Administration, Public Health, Healthcare Administration or related
field preferred.



License/Certificates: Board Certification through American Board of Medical
Specialists. Current state medical license without restrictions.



20% CLINICAL PRACTICE 20% Program, Clinical Internal (CM, 20% UM 40%
Administrative (provider relations etc)


Willing to work
in the office 4 days a week and 1 day of clinical practice


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