Administration - Management Job at Mercyhealth in Janesville, WI

A passion for making lives better.

At Mercyhealth, an award-winning, fully integrated healthcare delivery network serving southern Wisconsin and northern Illinois, our mission is healing in the broadest sense: promoting physical, emotional and spiritual well-being. We achieve this by dedicating our teams to the highest standards of quality, care, and innovation throughout our entire organization. By giving our all, we can ensure that others achieve maximum wellness, and that our organization achieves maximum success.

We are seeking an inspiring leader to join us as the Medical Director of our MercyCare Health Plans, a wholly owned subsidiary that links Mercyhealth together by offering a complete continuum of health care services to our membership, including seniors, individuals, and area employers and their employees.

MEDICAL DIRECTOR
MercyCare Health Plans
Janesville, Wisconsin

The critical thought leader we select for this important role will be accountable for identifying and promoting key strategies for continuously improving the outstanding quality and efficiency of care expected by our members. In addition to controlling costs through utilization management, case management, disease management and other strategies, this professional will direct, implement, and support quality and utilization-management strategies and business plans for the MercyCare Insurance Company markets. Responsibilities include:

• Overseeing all initiatives and ongoing work in clinical programs, NCQA, HEDIS, credentialing, compliance with federal and state regulations, and management of grievance and appeal processes.
• Constantly evaluating and benchmarking of the resource-management system including utilization and case management.
• Monitoring/reviewing treatment recommendations by participating and non-participating providers for quality, appropriateness, and cost-effectiveness.
• Monitoring the constantly changing provision of care environment for changes in technique, technology, and protocols, and providing recommendations regarding plan member services.
• Reviewing quality-of-care issues and referring them to appropriate parties.
• Providing leadership and communication to physician groups and Mercyhealth leadership on care quality and efficiency issues.
• Staffing/chairing the Medical Management Committee and its subcommittees.
• Acting as NCQA project leader and providing management support for managed-care accreditation programs.
• Working with managed healthcare staff to develop/maintain measurement indicators.
• Submitting/presenting reports on utilization and quality activities to the health plan board of directors.
• Monitoring and ensuring the efficiency of the UM/QM staff.
• Directly supervising Medical Management and Quality Management, including the medical data analyst and the clinical pharmacist.                     

Required Credentials

• Status as a medical doctor with appropriate state licensure.
• Current board certification in primary care, specialty, or emergency medicine.
• Five or more years of experience in direct patient care.
• Five or more years of experience in managed care or similar administrative role.
• Demonstrated leadership and relationship-building skills.

Give us your all, and receive all of these advantages.

In addition to opportunities to learn, grow, and advance, Mercyhealth offers health and dental insurance, vacation, matched retirement savings, and more.