Provider Job Details

Job Description

The Senior Medical Director assists the Associate Chief Medical Officer in promoting successful implementation of the medical, pharmaceutical and quality improvement management processes as Health Alliance. Responsible for analyzing complex medical situations and developing solutions within the limits of the member's benefits and the relevant policies. Serves on administrative and operational committees of Health Alliance as requested by the Associate Chief Medical Officer and or serves as medical adviser to the Medical Management, Quality Improvement, Provider Relations and Pharmacy departments. Interacts with network providers to ensure implementation of the Utilization Management, Case Management, Quality Improvement and Health Promotion/Disease Prevention programs.

May be responsible for new medical director on-boarding and training as well as other duties not assigned.

Job Functions:

• Analyzes complex medical situations and develops solutions within the limits of the member's benefit package and relevant policies.
• Serves on administrative and operational committees of Health Alliance Medical Plans as requested by the Associate Chief Medical Officer (i.e., Medical Directors' Committee, Quality Improvement Committee, Credentialing Committee, Pharmacy & Therapeutics Committee, Medical Policy Committee, etc.)
• Serves as the medical adviser to the Medical Management, Quality Improvement, Provider Relations and Pharmacy Departments.
• Interacts with network providers to ensure implementation of the Utilization Management, Quality Improvement and Health Promotion/Disease Prevention programs.
• Adheres to and enforces Health Alliance Medical Plans Administrative and Departmental policies and procedures.
• 100% Remote position

Experience Requirements:

• Doctor of Medicine from an accredited school of medicine; board certification in primary area of clinical practice
• 5 years of clinical practice experience beyond residency training
• 3-5 years (5 years preferred) of health plan (payer) experience required
• Experience/working knowledge of Medicare Advantage

About Carle

Based in Urbana, IL, The Carle Foundation is a vertically integrated system with more than 9,500 employees in its five hospitals, multi-specialty physician groups, health plan and associated healthcare businesses including the Carle Illinois College of Medicine, the world’s first engineering-based medical school. Carle is proud to be named a Great Place to Work®. Carle Foundation Hospital and Carle BroMenn Medical Center hold Magnet® designation, the nation’s highest honor for nursing care and Carle Foundation Hospital (CFH) ranks as one of America’s 50 Best HospitalsTM by Healthgrades®.