Medical Director

Job Description

Department:

NHI - Clinical

Reports to:

Deputy Director

Supervises:

N/A

Effective Date:

January 2023

Job Summary

This position is responsible for providing medical oversight and medical necessity of health care services provided to beneficiaries, targeting improvements in efficiency, quality, and satisfaction for patients and providers aimed to enhance and achieve the overall goals of NHI.

• Assists in the medical aspects of the NHI Emergency Overseas Treatment Programme.
• Documents clinical review findings, actions, and outcomes in accordance with RHSO policies, regulatory, and approved requirements.
• Provides medical leadership across NHI departments as needed
• Chair the Quality Improvement Committee
• Chair the Credentialing Committee
• Chair the Pharmacy and Therapeutics Committee
• Review all appealed claims denials
• Overturn/uphold pre-service and retrospective medical necessity appeals
• Approve/deny preauthorization request that do not meet medical necessity criteria per UM nurse review
• Provide support to the Clinical team for complicated cases as needed.
• Provide support to the pharmacy staff Review performance and utilization reports
• Prepare and present data to NHI staff, the NHI governing body and the public
• Direct specific aspects of the medical management program including Quality Improvement, Pharmacy , Disease Management and Wellness Initiatives
• Review performance and utilization reports
• Collaborate with Mgr. Referrals & Health Services for medical evacuations.
• Identifes and resolves problems, and collaborates in process improvements.
• Provides support to the clinical management staff as needed.
• Prepares and presents data to NHI staff, NHI governing body, and the public.
• Member of the Auditing of Providers Team.
• Performs other duties or special projects as required or as assigned.

Certifications/Licenses Required:  Board Certified Medical Director

• Sound knowledge of the regulations governing the Social Security Board/NHI.
• Deep understanding of the healthcare and insurance business.
• Hands-on experience in utilization and coverage review in a health plan.
• Substantial experience in using electronic systems in the provider or payer setting.
• Strong belief in Evidence Based Medicine, and familiarity with current medical issues and practices.
• Sound knowledge of the managed care industry.
• Leadership ability in work setting.  Flexible, willing to learn, and anticipates the needs of self and staff.
• Ability to set a positive tone for employees during their day.
• Comfortable in a fast-paced environment with frequent deadlines; high energy, self-motivated and proactive.
• Ability to manage issues requiring problem resolution and conflict management with excellent interpersonal and intervention skills.
• Excellent communication and interpersonal skills.
• Knowledge of business operations, including effective budget development and management processes.
• Attention to detail and commitment to excellence, demonstrated by the delivery of quality and timely outcomes.

Physical Requirements:

The physical demands are minimal and typical of similar jobs in comparable organisations.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties of the position.