at Health Care Service Corporation in Chicago, Illinois, United States
Job Description
At HCSC, we consider our employees the cornerstone of our business and the foundation to our success. We enable employees to craft their career with curated development plans that set their learning path to a rewarding and fulfilling career.
Come join us and be part of a purpose driven company who is invested in your future!
Job Summary
Responsible for planning and implementation of medical policies and programs and strategic involvement with the cost of health care. This position is primarily accountable for advising and implementing medical guidelines, management of high-cost claimants, payment guidelines, claim reviews, and process improvements. Is in addition, to various degrees, this position will perform physician level review using applicable systems and maintain effective relationships with physicians, hospitals, and medical service companies to respond to and resolve problems, serving as the final decision maker for clinical determination. This position will also head projects to promote effective medical policy relative to the membership of these major accounts. Finally, this position is responsible for leading and developing a team of medical directors.
1. Lead and develop a team of Medical Directors, to include hiring, onboarding, developing, and managing performance. Ensure the efficacy of the Medical Directors, advise and serve as the final decision maker for clinical determination.
2. Perform physician level review and resolution of areas such as, but not limited to, underwriting issues, pre-certification, utilization review, case management, appeals, and medical records to determine medical necessity, custodial care, risk, cosmetic surgery, applicability of procedural coding and reconsiderations. May recommend recoupment of monies paid for services in excess of the amount indicated by medical necessity or concurrent care.3.
3.Provide medical interpretations and advice to assigned corporate areas; e.g., Utilization Review, Customer Service, Claims, Underwriting, Provider Relations, Legal, Marketing, Coding and Pricing, etc. or customers e.g., National Accounts, HMO, etc.
4. Develop medical policy and review parameters, guidelines and payment policies used in prepayment reviews; determine proper allowances to be granted in unusual cases. Review physician profiles to determine their validity.
5. Manage and provide training to ensure the effective review of medical records and claims. Provide liaison/training regarding Medical Necessity Review, Utilization Management, applicable systems, etc.
6. Maintain external relationships and act as a liaison with physician, hospital administrators and medical service companies, as a means for resolving reasonable charge problems and providing education relating to corporate medical policy and potentially the various aspects of allowable amounts. May represent the corporation at various state and national medical association meetings as required.
7. May oversee process changes and improve process efficiency involving immediate upstream and downstream partners.
8. Serve as lead/subject matter expert for one or more of the following areas: System upgrades/changes, Medical Policy changes and interpretation, vendor issues, AoC Initiatives, HCSC Internal Policies, MCG utilization, Accreditation, Pharmacy reviews, appeals process, etc.
9. Serve as subject matter expert on applicable systems, in order to train and advise others.
10. Assist in the planning activities for the Medical Division.
11. Must be located in a state or territory of the United States when conducting a peer clinical review and an appeal consideration for the purpose of Utilization management.
12. Communicate and interact effectively and professionally with co-workers, management, customers, etc.
13. Comply with accreditation, statutory and regulatory requirements, HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
14. Maintain complete confidentiality of company business.
15. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
JOB REQUIREMENTS:
* Physician (M.D. or D.O) with a current and unrestricted physician license in a state or territory of the United States
* Maintain Board... For full info follow application link.
HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
