Director (a) Clinico (a)

Regular

Exempt

Provides clinical consultation for IPA and PCP Programs regarding Utilization Management and Coordinated Care. In addition, provides management support for clinical programs monitored by IPA Administration.

ESSENTIAL FUNCTIONS

• Evaluates utilization reports to identify primary care physicians (PCPs) with overutilization in their panel
• Implement interventions with Primary Care Physicians to provide guidance and thus guarantee proper compliance with:

a. Requirements and purpose of the Medicare Advantage program
b. CMS policies, procedures, and regulatory structure
c. The advantage of proper medical management
d. The importance of the concepts considered in the premium and the process of cost containment in pharmacy, and the importance of the proper and timely processing of medical documentation
e. The importance of monitoring and complying with care and preventive care components focused on achieving quality measures.
f. Master the process of interpreting utilization reports

• Direct the Regional Medical Directors team in the planning and execution of PCP intervention to improve quality of care and utilization and monitor the PCP outreach achieved
• Meets with IPAs administrators and/or medical directors to discuss performance in terms of quality and utilization parameters
• Evaluates IPAs medical management plans
• Provides consultation services for special projects and/or programs, such as Specialist Networks, MCS IPA Virtual, VIP Networks, review of educational lectures, and clinical strategies, among others
• Takes part in meetings as an expert to discuss and contribute to developing clinical strategies to achieve appropriate management of components related to the cost-effective management of medical services and clinical quality objectives
• Takes part in meetings with other departments and units to guarantee improvement of service-oriented processes and procedures
• Supervises, monitors, trains, and evaluates its personnel to comply with his/her role as a supervisor, to assure that his/her personnel fulfill their work plan and comply with their essential functions, and that they behave in accordance with the policies, standards, norms, and procedures of the Company
• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices

MINIMUM REQUIREMENTS:

Education: MD Degree (preferable).

Experience: At least eight (8) years of experience in directed care areas.

Certifications/Licenses: N/A

Other: N/A

Languages:
Spanish - Advanced (writing, conversational, and comprehension)
English - Advanced (writing, conversational, and comprehension)

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