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Chicago, IL Full Time Posted: Monday, 11 February 2019
MEDICAL DIRECTOR - Provider Performance - MCO

This UNIQUE opportunity will focus on provider engagement and achieving performance results in value based care by providing support and influence and bringing insight, innovation and opportunities to the physicians. MD develops understanding of value-based contracts across lines of business in a region and around cost of care and analytic tools and reporting.

MD will develop alliances with the provider community through the development and implementation of the medical management programs.

May represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.

Represents the business unit at appropriate state committees and other ad hoc committees

Responsible for the provider performance program by persuading physician groups, local markets and medical staff of the value of the program for members improved quality of care, lower cost of services and improved financial reimbursement for providers who are successful in managing quality, access and overall costs.

Monitors competitor products and internal provider performance reporting capabilities and responds with recommended enhancements

Accountable for achieving performance results in value based care by engaging, influencing and supporting physicians. Engages with providers in joint operating committees and builds relationships with clinical leadership of provider collaboration groups.

Designs and develops market interventions leveraging existing tools that will drive performance in value-based care. Provides expertise, captures and shares best practices across regions to provider partners as well as other medical directors.

Collaborates with provider engagement team to bring insight, innovation and opportunities that help drive performance.

Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.

Provides medical leadership for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services

Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.

Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.


- MD or DO, must be board certified preferable in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine).

- Actively practicing physician.

- Willing to travel across IL for provider meetings and engagements.

- Previous experience within a managed care organization is preferred.

- MUST have experience with value base care and provider performance

- Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred. Experience treating or managing care for a culturally diverse population preferred.

- As an outward facing position, this role requires exceptional interpersonal skills, good communication skills and collaboration

- Current IL medical license without restrictions.

Chicago, IL, United States of America
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2/11/2019 4:18:46 AM

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