Medical Director - Health Care Management (HCM)

The HAP Medical Director represents the plan and its interests in network, medical group, and other forums pertinent to the assurance of high quality of health care, effectiveness and efficiency. 

The Medical Director develops, implements and executes strategies for related to HAP’s population health focus (care management, utilization management, behavioral health) to achieve targets. The Medical Director supports the creation of business processes and departmental goals and objectives between provider contracting, provider relationship management, medical directors and medical management to optimize effectiveness and efficiency. Work in extremely close cooperation and collegially with nurses to achieve HAP’s UM and medical management objectives. Also works with other HAP departments as necessary to fully integrate strategies. 

DIRECT REPORTS: As determined by scope and authority 

KEY RELATIONSHIPS: Senior Vice President, Chief Medical Officer AVP, Population Health Management AVP, Quality Improvement and Management Senior Director Medicare Stars, HEDIS, and Reporting HAP Medical Directors Vice Presidents within Pharmacy, Strategic Development, Provider Relations Vice President, Medicare/MMP Operations Various HFHS Executives/Clinical Leaders and non-HFHS network leaders 

PRINCIPLE DUTIES AND RESPONSIBILITIES: 

• Supports activities that advance the overall population health and quality management programs at HAP to the next level of service and promotes interdepartmental integration and collaboration to enhance clinical outcomes for members 
• Contributes to ongoing efforts to assure that HAP PHM/QM activities are appropriately integrated into strategic direction and operations of the Henry Ford Health System (HFHS) 
• Provide physician expertise and leadership focused primarily on UM operations specifically inpatient and outpatient reviews, working on a day to day basis with UM nurses to review cases regarding medical necessity criteria. 
• One-to-one collaborative conversations with physicians/providers as needed 
• Provide support to initiatives that target appropriate use of medical services including meeting with contracted providers when necessary 
• Review member and provider appeals of medical necessity denials to ensure a fair and unbiased review of initial adverse determinations. 
• Identify opportunities to improve end to end processes that aim to identify and correct appropriate use of medical services. 
• Demonstrate competency at reviewing utilization data and working with analysis team to identify potential root causes of overuse. 
• Review HAP benefit structure to assure compliance with current medical practice, regulatory requirements and comparability with other health plans. 
• Design, develop and take accountability for plans to manage appropriate use when assigned 
• Perform additional specific accountable duties aligned with individual’s skill set as defined by Senior Vice President, Chief Medical Officer/Vice President Population Health and Quality including but not limited to: 
  • Support of specific clinical initiatives in specific lines of business (commercial, Medicare, Medicaid, MMP) 
  • Clinical liaison support of key PHM programs 
  • Clinical support of key external relationships with employers or provider groups