Medical Director-MyCare-Ohio-MMP-NEW PROGRAM

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Responsibilities for a Medical Director include:

The Medical Director for UnitedHealthcare Connected for MyCare Ohio will be actively involved in all major clinical and quality management components of the program, including the following:

1.       Development, implementation and medical interpretation of medical policies and procedures including, but not limited to:

i.                     Service authorization;

ii.                   Claims review;

iii.                  Discharge planning;

iv.                 Credentialing;

v.                   Referral management; and

vi.                 Medical review included in the ICDS Plan Grievance System;

2.       Administration of all medical management activities of the ICDS Plan;

3.       Is responsible for ensuring the clinical accuracy of all Part D coverage determinations and redeterminations involving medical necessity; and

4.       Serves on Health Plan Utilization Management and Quality Improvement Committees. 

Other responsibilities of the Medical Director may include:

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  Collaborates with the care coordination team and other clinical staff to establish and implement clinical programs to support and meet Health Plan goals. 


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  Actively involved in all major clinical and quality management components of the plan


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  Conducts Medical Director activities primarily focus on support of the daily review activities and external interaction and communication with network physicians. 


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  Interacts, communicates, and collaborates with network and community physicians, hospital leaders, and other vendors regarding clinical care and services for enrollees.


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  Facilities and uses performance data to guide interactions.


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  Oversees provider telephonic review and discussion, and shares tools, information and guidelines related to quality, cost-effective health care delivery and quality of care.


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  Oversees documentation of case review findings, actions, and outcomes in accordance with policies; meets health plan inter-rater reliability guidelines.


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  Serves as a clinical resource, coach, and leader for Health Plan Clinical team.


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  Shares best practices with other medical directors and clinical leaders from other regional sites.


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  Conducts weekly team meetings and rounds for communication, feedback, problem solving, staff training and development and sharing of program results. 


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  Facilitates access to clinical specialty panel physicians to assist in complex or difficult cases.


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  Develop and monitors utilization reports by product line, identifying changes in utilization or access patterns and monitor overall trends on a weekly basis.


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  Interacts with Health Plan leadership to develop HCQAI plans and to implement strategic initiatives and tactics to address areas of concern and monitors progress towards goals.


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  Interacts with RCMO to ensure coordinated approach to delivery system providers.


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  Participates in design and development of care programs and serves on national committees as requested.