Medical Director - ID Hospice Medical Review - Contract
Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.
Qlarant has a home-based contract opportunity for a physician with experience providing hospice services. In this role, you will perform reviews of medical records and related documentation for medical necessity. In addition, this position supports review determinations during the appeals process including depositions and court testimony. It is preferred that the selected physician is located in Idaho, but other states are acceptable.
Please note: This is a contractual arrangement with an hourly rate. There are no guaranteed hours as the work is assigned on an as needed basis.
This position supports our Unified Program Integrity Contract (UPIC) team's efforts to identify and investigate the fraud, waste and abuse (FWA) impacting our nation's Medicare and Medicaid programs. Our Cerritos-based UPIC West team is responsible for FWA investigations covering 16 Western states and territories.
While medical review and support of review determinations will be the primary responsibilities of this position, the Medical Director job description includes the following essential duties and responsibilities. Other duties may be assigned.
- Provides clinical information to teams
- Medical Review Oversight may include:
- Physician peer review activities
- Criteria development and assessment
- Correspondence regarding review determination
- Recruitment, credentialing, and training of expert physician reviewers
- Managing the expert physician advisory network in specific geographic areas
- Serving on external committees
- Professional Relations may include:
- Interfacing with external organizations including physician specialty groups, hospital associations, medical societies, affiliates contractors, and state and federal agencies
- Discussing specific clinical issues with attending physicians
- Health Care Quality Improvement/Assurance may include:
- Leading and/or participates in quality improvement projects as needed
- Providing clinical input to specific projects as required by the organization or contractors
- Supporting project managers or teams with specific collaborative projects as needed
- Maintaining working knowledge of current quality improvement issues and tools
To perform the job successfully, an individual should demonstrate the following competencies:
- Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses experience to complement data.
- Quality Management - Looks for ways to improve and promote quality.
- Business Acumen - Understands business implications of decisions; Demonstrates knowledge of market and competition; Aligns work with strategic goals; Contributes to the development of responses to Requests for Proposals.
- Communication - Utilizes established protocols to communicate in an effective and timely manner with coach, project staff, and contract members.
- Judgment - Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
- Design - Generates creative solutions; Translates concepts and information into images; Uses feedback to modify designs; Applies design principles; Demonstrates attention to detail.
- Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.
- Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
- Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
- Planning/Organizing - Prioritizes and plans work activities; Sets goals and objectives; Completes work within required contractual timelines.
- Organizational Support - Supports organization's goals and values; Benefits organization through outside activities.
Other Skills and Abilities:
- Uses knowledge and experience to interpret medical polices and guidelines. Complies with specific contract requirements.
- To perform this job successfully, an individual should have knowledge of Word Processing software.
- Must have basic understanding of the use of the computer.
Education and/or Experience:
- Doctoral degree (MD) with at least 5 years Hospice services clinical experience with a focus on quality improvement and/or quality assurance. Hospice services experience must be current or within the past 5 years.
- Advanced degree in public health or health care administration preferred. May consider an equivalent combination of education and experience.
- Board Certification in Hospice required.
- Knowledge of Medicare/Medicaid required.
- Previous experience as a medical reviewer strongly preferred.
- Must be willing and able to support review determinations during the appeals process including depositions and court testimony.
- Microsoft Office proficiency at a level that allows timely completion of deliverables.
Certificates, Licenses, Registrations: Valid, current, active, and unrestricted clinical physician license and practice as a health professional in a state or territory of the United States.
Travel Requirements: Travel requirements vary based on contract requirements may require periodic overnight and/or local travel. Must be willing to travel in accordance with company and contract needs.
Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.