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TRICARE Prior Authorization Medical Director - Phoenix or Colorado Springs
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | Colorado Springs, CO Colorado Springs, Colorado |
About this job
UnitedHealthcare Military & Veterans (UHC M&V) is part of the family of companies that make UnitedHealth Group one of the leaders across the US health care system.
We serve those who serve our nation, providing quality health care services to millions of military beneficiaries across the West.
Our commitment to helping people live healthier lives, and to continue the honor, satisfaction, and quality of the TRICARE military health benefit program is greater than ever. Our efforts complement the Military Health System to demonstrate the best blend of public and private health care solutions.
It's not just business as usual. It is one of our proudest endeavors.
The Medical Director works actively to implement and administer medical policies, utilization management programs to include pre-service review, integrate physician services, quality assurance, and regulatory compliance programs with medical service and delivery systems to ensure the best possible quality health care for TRICARE beneficiaries. Accountability for ensuring that initiatives focus on affordability, clinical excellence, TRICARE medical management program requirements and are implemented and successfully managed to achieve performance expectations. This position requires working closely with utilization management, primarily with prior authorization review. The Medical Director advises leadership on improvement opportunities regarding clinical programs that impact medical expense. The Medical Director for UHC M&V also provides leadership to clinical staff through case consultation and case review and provides feedback on clinical performance to senior leaders with plans for clinical performance improvement. The impact of work is at the operational level for TRICARE. The Medical Director is accountable to manage resource allocation as is applicable to medical management practices under his or her scope of responsibility.
SUMMARY OF JOB RESPONSIBLITIES:
The Medical Director is responsible for clinical leadership within UHCM&V and reports to the Senior Medical Director for UHC M&V.
OUTLINE OF ESSENTIAL JOB RESPONSIBILITIES/FUNCTIONS TO INCLUDE BUT NOT LIMITED TO:
1. Develops, coordinates and participates in medical management program design, development, implementation, oversight and monitoring as a medical leader within UHC M&V team:
- Establishes and oversees standards of practice for TRICARE. Assures adherence to UHG and MHS/DOD clinical practice guidelines and TRICARE Manuals, as well as best clinical practices according to evidence-based medicine.
- Working collaboratively with the Medical management senior leader in the development and implementation of medical expense management initiatives and medical management program development.
- Oversees evaluation and management of medical practices within the requirements of a Multi-Function Peer Review Organization.
- Assigns, directs, and reviews the work of other medical staff, as assigned.
- Plans and facilitates training and development of clinical staff to improve performance.
- Provides for and recommends clinical program enhancements and quality improvements that adhere to the TRICARE requirements and reflect emerging clinical solutions and best evidences based practices.
- Supports, communicates and facilitates TRICARE wide clinical programs and policies.
- Provides clinical education to clinical staff to ensure TRICARE medical management program success
- Analyzes population-based reports to refine management activities, investigate and define variation, and ensure conformance to expected standards and targets.
- Accountabilities include oversight of medical & clinical processes with a focus on implementing plans of care that meet accepted guidelines and protocols and ensure that optimal and appropriate medical & clinical services are provided.
- Ensures compliance with policies, procedures, bylaws, regulatory requirements, and best practice guidelines.
- Participates in the production of setting performance standards for clinical staff that aligns with program standards and the TRICARE contract. Monitors, assesses, reviews and evaluates clinical employee performance based on the established standards.
- Works with the Senior Medical Director to monitor, evaluate and manage the department/division budget; conduct trend analysis, and develop the approach and interventions to improve performance. .
2. Communicates effectively.
- Provides clear and concise verbal and written instructions to ensure that instructions are understood.
- Completes peer to peer communication, as required
- Provide beneficiary case consultation for providers, MTF providers and staff, and UHC M&V clinical staff
- Listens and asks for feedback from staff, physicians and customers.
- Ensures that TRICARE network providers are kept up to date on changes that are occurring.
- Addresses healthcare issues appropriately.
- Uses the computer system in order to obtain beneficiary, clinical, research, and physician information.
3. Consults and coordinates with health care providers working in other departments and in other business units across UHG.
- Provides assistance to the health care providers by answering questions regarding
beneficiary care.
- Educates and interacts with network and group providers as well as clinical and case management staff regarding utilization practices and effective resource management.
- Works in coordination with health care providers and case managers on high-risk beneficiaries to put the most appropriate treatment plan in place for beneficiaries.
4. Works with all other staff in UHC M&V as a member of the team
- Ensures that UHC M&V staff understand the goals and objectives of the MHS for TRICARE beneficiaries and assists senior leadership to lead teams and adhere to the goals to comply with TRICARE requirements
- Updates staff on a regular basis, as appropriate.
- Participates in fulfilling the mission, vision, goals and objectives of the organization.
- Oversees and participates on committees within UHC M&V and UHG.
- Ensures a safe work environment for staff who directly interact with beneficiaries
5. Participate in the development and implementation of the TRICARE clinical quality management program
- Ensures consistent and continual monitoring of quality of care delivered.
- Investigates selected cases reported as deviating from accepted standards and takes appropriate actions.
- Participate in the HEDIS-like quality measure data extraction, reviews, and analysis. Provides recommendations for improvement of HEDIS-like measures as established within TRICARE and other quality metrics set by UHC M&V.
- Reviews completed charts on a regular basis as part of the Multi-function Peer Review Organization activities and for UHC M&V clinical staff monitoring and performance oversight.
- Provides and receives consistent feedback on the quality of care being delivered.
- Ensures URAC, NCQA and other regulatory standards are met as they apply to UHC M&V and TRICARE.
- Abides by policies, procedures and bylaws.
Requirements
Unrestricted USA Medical Licensed Physician required.
Must be licensed in one of the 21 states in the TRICARE West Region
· Currently Board Certified in ABMS specialty required
· 5+ years clinical practice experience required
· Utilization Management experience required
Knowledge and competence with the Microsoft Office Suite is required.
This is a full-time position and work hours may include weekends, evenings and holidays.
This is an office-based position in Phoenix, AZ or Colorado Springs, CO.
Telecommuting is not available
· Excellent telephonic communication skills; excellent interpersonal communication skills.
· Ability to develop relationships with network and community physicians; Military Treatment Facility physicians; and other providers.
· Strong knowledge of managed care industry.
· Excellent project management skills.
· Data analysis and interpretation skills.
· Ability to focus on key metrics.
· Excellent presentation skills for both clinical and non clinical audiences.
· Familiarity with current medical issues and practices.
· Creative problem solving skills.
· Visibility and involvement in medical community.
· Strong team player and team building skills.
· Supervisory skills including clinical mentoring and coaching skills.
· Proven Quality Management experience
As a government contractor, this position requires U.S. citizenship and proof of favorable adjudication following submission of Department of Defense form SF85P.
· United States Citizenship
· Ability to obtain favorable adjudication following submission of Department of Defense form SF86 .
As a requirement of UnitedHealth Group's contract with the Department of Defense, this position requires U.S. citizenship and proof of favorable adjudication following submission of Department of Defense form SF86 , (the National Agency Check or “NACâ€). Successful completion of the NAC process is a requirement for continued employment in this role. NAC processing will be initiated by our TRICARE Security Officer post-offer, and can take 3-6 months for a final decision communication from the Department of Defense. Candidates will be allowed to begin employment with UnitedHealth Group in this role based on an interim clearance, and final results will be communicated as they are received. Failure to obtain final NAC approval will result in termination from this role.
Careers at UnitedHealthcare Military & Veterans: When it comes to their health care, the men and women who help keep the peace deserve the greatest peace of mind. That's why UnitedHealthcare is the organization that's called on to serve them and their loved ones. We're all about finding better ways to help improve their lives no matter where life may take them. So our career opportunities take challenge to a higher level. If you have a commitment to quality that mirrors our commitment to the men and women of the armed forces, take time to learn more about the career paths available here. It's a genuine opportunity to do your life's best work.
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, or national origin.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.
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