Overview Controlling cost through Utilization Management, Case Management, Disease Management and other cost-containment strategies is essential to the success of MercyCare. Equally important is maintaining and improving the outstanding quality of care expected by our members. The Medical Director is a critical Thought Leader in identifying and promoting key strategies for continuously improving the quality and efficiency of care delivered to Members. The Medical Director will direct, implement and support quality and utilization management strategies and business plans for the MercyCare Insurance Company markets. This includes oversight of all initiatives and ongoing work in clinical programs, NCQA, HEDIS, credentialing, compliance with federal and state regulations, and management of grievance and appeals processes.The key duties of this position include the development, implementation and maintenance of quality management infrastructure designed to achieve successful NCQA review and accreditation in all areas of review, and to set direction and oversee clinical and service monitoring activities. Responsibilities Essential Duties and Responsibilities Constant evaluation and benchmarking of the resource management system including, but not limited to, utilization and case management. As needed, monitor/review of treatment recommendations by participating and non¬participating providers for quality, appropriateness and cost-effectiveness. Monitor the constantly changing provision of care environment for changes in technique, technology and protocols and provide recommendations regarding appropriateness of services available to Plan members. Review quality of care issues and refer to appropriate individuals and committees. Provide leadership and communication to internal and external physician groups and Mercyhealth Leadership on issues affecting the quality and efficiency with which care is delivered to HMO members. Staff and chair the Medical Management Committee and all of its subcommittees. Act as NCQA project leader providing necessary management support for specified managed care accreditation programs including HEDIS measure performance. Interact regularly with major employers and benefits managers of local employers and regional coalitions. Work with the managed health care staff to develop and maintain measurement indicators of core processes essential to successful managed health care operations. Periodically submit and present utilization and quality activities to the Health Plan Board of Directors. Through management skills, monitor and ensure optimum efficiency of the UM/QM staff. Directly supervise the Medical Management and Quality Management Departments, including the medical data analyst and clinical pharmacist. Meets regularly with the MercyCare Leadership team Other duties as assigned Culture of Excellence Behavior Expectations To perform the job successfully, an individual should demonstrate the following behavior expectations: Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals. Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions. Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals. Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue. Education and Experience Medical Doctor with appropriate State licensure, Board Certification in a primary care specialty or Emergency Medicine. Minimum 5 years' experience in direct patient care and 5 years' experience in managed care or similar administrative role. Certification and Licensure N/A Skills and Abilities Experience as a Medical Director or Associate Medical Director for a Provider owned HMO is highly desirable. High level of independent thinking required and management experience in a changing environment is desirable. Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures. 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. Project Management - Develops project plans; Coordinates projects; Communicates changes and progress; Completes projects on time and budget; Manages project team activities. Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others. Interpersonal Skills - Ability to lead, facilitate, coach and manage. Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things. Negotiation - Ability to communicate effectively and think quickly under stressful situations. This position is able to comprehend complex legal and administrative issues, creatively problem solve, and come to mutual agreement in a positive manner. Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings. Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information. Change Management - Develops workable implementation plans; Communicates changes effectively; Builds commitment and overcomes resistance; Prepares and supports those affected by change; Monitors transition and evaluates results. Delegation - Delegates work assignments; Matches the responsibility to the person; Gives authority to work independently; Sets expectations and monitors delegated activities; Provides recognition for results. Leadership - Exhibits confidence in self and others; Inspires and motivates others to perform well; effectively influences actions and opinions of others; Accepts feedback from others; Gives appropriate recognition to others. Managing People - Includes staff in planning, decision-making, facilitating and process improvement; Takes responsibility for subordinates' activities; Makes self available to staff; Provides regular performance feedback; Develops subordinates' skills and encourages growth; Solicits and applies customer feedback (internal and external); Fosters quality focus in others; Improves processes, products and services.; Continually works to improve supervisory skills. Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness. Cost Consciousness - Works within approved budget; Contributes to profits and revenue; Develops and implements cost saving measures; Conserves organizational resources. Ethics - Treats people with respect; Keeps commitments; inspires the trust of others; Works with integrity and ethically; Upholds organizational values. Organizational Support - Follows policies and procedures; Completes administrative tasks correctly and on time; supports organization's goals and values; Benefits organization through outside activities. 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. Motivation - Sets and achieves challenging goals; Demonstrates persistence and overcomes obstacles; Measures self against standard of excellence; Takes calculated risks to accomplish goals. Planning/Organizing - Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives; Organizes or schedules other people and their tasks; Develops realistic action plans. Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments. Adaptability - Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events. Attendance/Punctuality - Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time. Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals. Completes tasks on time or notifies appropriate person with an alternate plan. Initiative - Volunteers readily; Undertakes self-development activities; Seeks increased responsibilities; Takes independent actions and calculated risks; Looks for and takes advantage of opportunities. Innovation - Displays original thinking and creativity; Meets challenges with resourcefulness; Generates suggestions for improving work; Develops innovative approaches and ideas; Presents ideas and information in a manner that gets others' attention. Language Skills Ability to write reports, business correspondence, and presentations. Ability to effectively present information and respond to questions from groups of physicians, managers, directors, executives, and other system personnel. Mathematical Skills Ability to apply concepts such as fractions, percentages, interest, ratios, and proportions to practical situations. Reasoning Ability Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Computer Skills To perform this job successfully, an individual should be proficient with Microsoft Office applications and have the ability to learn appropriate business applications and software as necessary. Special Physical Demands The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations. While performing the duties of this Job, the employee is regularly required to sit; use hands to operate a keyboard, talk, and hear. The employee is occasionally required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus. Level of Supervision Supervises Manages subordinates in the Medical Review and Quality Departments. Is responsible for the overall direction, coordination, and evaluation of subordinates. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. Benefits Mercyhealth offers a generous total rewards package to eligible employees including, but not limited to: · Comprehensive Benefits Package: Mercyhealth offers a retirement plan with competitive matching contribution, comprehensive medical, dental, and vision insurance options, life and disability coverage, access to flexible spending plans, and a variety of other discounted voluntary benefit options. · Competitive Compensation: Mercyhealth offers market competitive rates of pay and participates in various shift differential and special pay incentive programs. · Paid Time Off: Mercyhealth offers a generous paid time off plan, which increases with milestone anniversaries, to allow employees the opportunity for a great work-life balance. · Career Advancement: Mercyhealth offers a number of educational assistance programs and career ladders to support employees in their educational journey and advancement within Mercyhealth. · Employee Wellbeing: Mercyhealth has a focus on wellbeing for employees across the organization and offers a number of tools and resources, such as an employer-sponsored health risk assessment and a Wellbeing mobile application, to assist employees on their wellbeing journey. · Additional Benefits: Mercyhealth employees have access to our internal and external employee assistance programs, employee-only discount packages, paid parental and caregiver leaves, on-demand pay, special payment programs for patient services, and financial education to help with retirement planning. #MHGM123