COMMITTEE FUNCTIONS AND LEADERSHIP

a.    Chairperson of the Utilization Management Committee, supervises Ambulatory Care Associate Medical Directors or community physician designees.

b.    Chairman of UM Subcommittee

c.    Medical Director Lead for identified clinical initiatives or project teams as appropriate

d.    Ensures that Ambulatory Care AMDs have appropriate training regarding clinical guidelines with interrater reliability

e.    Member of the Quality Management Committee.

f.     Provide direction to the staff regarding the agenda and schedule of clinical committee meetings; assist as needed in preparing the necessary materials to conduct the meetings.

g.    Attend and provide clinical presentations at IPA Board meetings, General Membership meetings, the Medical Leadership Council, and Physician Advisory committees.

h.    Develop educational programs for the physician network to enhance the delivery of patient care.

        NETWORK MANAGEMENT/PROVIDER CONTRATING

a.    Identify gaps in the IPA network and assist in identifying and recruiting new providers.

b.    Facilitate collegial provider relations with the IPA physicians and general medical community. Provides feedback and education to IPA physicians regarding UM Initiatives

c.    Act as the main point of contact for physicians who wish to speak directly about authorization requests and follow up information.

d.    Assess the adequacy of information being provided by the IPA to the IPA’s providers and assist in development of any new or revised materials.

e.    Attend periodic health plan and hospital meetings on issues pertaining to the IPA as needed.

f.     Assist staff from a clinical perspective in development of fee schedules or payment methodologies.

g.    Works collaboratively with the Medical Director of Quality to provide clinical input required for the staff to create and deliver physician performance reports to enhance performance of the physician network.

       HEALTH PLAN RELATIONS

a.    Establish and foster strong working relationships with the health plan Medical Directors

b.    Interact with health plan medical directors on specific cases as needed.

        CLAIMS/REVENUE RECOVERY

a.    Assist claims processing staff in review of medical claims for unbundling of services or other inappropriate billing practices.

b.    Assist claims and revenue recovery staff by reviewing and authorizing cap deductions.

        MEMBER SERVICES

a.    Assist the IPA member services staff when necessary in resolving individual member complaint issues.

b.    Review member services trend activity and interact with individual providers as necessary.

        FINANCE

a.    Provide assistance in analysis of medical cost trends.  Formulate and make recommendations from a clinical perspective based upon these analyses.

b.    Interact with staff to develop reports to monitor medical costs and formulate recommendations from a clinical perspective based upon these analyses. 

EDUCATION and/or EXPERIENCE: 

1.    Possess the education, training, and professional experience in medical or clinical practice to evaluate specific clinical issues to make medical necessity determinations and to make decisions that deny or modify necessity determinations and to make decisions that deny or modify services based on medical necessity.

2.    Possess sufficient clinical knowledge to interact with the physician members of the IPA in all major medical specialties.

3.    Have at least three years of clinical practice in direct patient care; and at least three years medical management experience in a managed care setting.

4.  Strong understanding of capitation and risk pools as it relates to an IPA setting

5.  Able to offer advice and mentorship to all Clinical Services personnel

6.  Act as a strong clinical resource to the Clinical Services department

7.  Able to supervise Associate Medical Directors under your direct management

LICENSES, CERTIFICATES, REGISTRATIONS:

1.    The Medical Director of Ambulatory Care must hold a valid, unrestricted license to practice medicine in the State of California.

2.    Board certification in the chosen specialty.