Department: 510701 Administration
Facility: Hometown Health
Reno, NV
Schedule: Full Time - Eligible for Benefits
Shift: Day
Hours:
Job Details:
  • Position Purpose:

    Under administrative direction of the Medical Director – HTH, the Medical Director - Hometown Health will work with the Hometown Health Services Director and team to optimize the outcomes for the members with regard to the Utilization management, Quality management, and network management program.  He/she will serve as a primary liaison with contracted physicians to help them achieve their performance, quality, and care appropriateness goals for HTH members.

     

    Nature and Scope:

    Said duties shall include, but not be limited to, the following:

     

    Utilization Review activities on behalf of the health plan

     

    Working knowledge of  ICD-9, CPT, HCPCs codes and in process of migrating to ICD-10

    -          Working knowledge of DRGs, Milliman and Interqual guidelines;

    -          Knowledge of claim payment methodologies and physician billing practices

    -          Excellent communication skills and experience in interacting with colleagues and peers

    -          Knowledge of multiple lines of health insurance business practices to include HMO, PPO, TPA, Self Insured, and MAPD product lines.

    -          Ability to utilize data to track and trend line of business and physician practice patterns

    -          Knowledge of CMS and Department of Insurance guidelines for medical necessity denials

    Oversee Case Management plans of care on behalf of the health plan  

    -           Participate in case management rounds on site at Renown Hospitals on a PRN basis as well as join in office rounds daily

    -          Ability to assist in making transition of care recommendations based on plan benefit design

    -          Use data to make recommendations for program implementation and change to better manage bed day utilization

    Review of medical credentialing files prior to presentation to committee with recommendations for provider additions to the network

     

    Work with the community physicians in performance and coding improvement activities for the Medicare Advantage plan for Risk adjustment and quality improvement activities.

     

    Drives quality initiatives such as STARS, HEDIS, HCC, and member satisfaction with providers

     

     

    This position does not provide patient care.  

    Minimum Qualifications:  Requirements - Required and/or Preferred

    Education:

    Must have working-level knowledge of the English language, including reading, writing and speaking English. Medical Degree from Accredited University

    Experience:

    Minimum of five (5) years practice experience.  Experience in managed care environment which includes significant involvement with Medicare Advantage plan, Disease management, and utilization/quality issues.  Accreditation experience a plus.  .  Demonstrated leadership and administrative and medical ability of high caliber

    License(s):

    State of Nevada Physician’s License

    Certification(s):

    Board certified  

    Computer / Typing:

    Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.



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