Job Details: Medical Director

Company: Health Net, Inc – With the support of more than 9,500 Health Net associates, we're building secure futures for our members, and at the same time, for our company.

Description: Health Net, Inc. (NYSE: HNT) is among the nation's largest publicly traded managed health care companies. Health Net's mission is to help people be healthy, secure and comfortable.
The company's POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals. For more information on Health Net, Inc., please visit the company's Web site at www.healthnet.com

JOB SUMMARY:
The Medical Director works actively to implement and administer medical policies, disease and medical care management programs, integrate physician services, quality assurance, appeals and grievances, and regulatory compliance programs with medical service and delivery systems to ensure the best possible quality health care for Health Net members.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
• Supports the Health Plan Chief Medical Officer or Senior Medical Director by effectively implementing the Plan initiatives and programs.
• Leads the effective operational management of assigned departments or functions with an emphasis on execution, outcomes, continual improvement and performance enhancement.
• As a representative of the Health Net Plan, assists in maintaining relationships with key employer groups, physician groups, individual physicians, managed care organizations, and state medical associations and societies.
• Participates in quality improvement programs to assure that members receive timely, appropriate, and accessible health care.
• Provides ongoing compliance with standardized Health Net, Inc. systems, policies, programs, procedures, and workflows.
• Participates and supports communication, education, and maintenance of partnerships with contracted providers, provider physician groups and IPA's and may serve as the interface between Plan and providers.
• Responsible for recommending changes and enhancements to current managed care, prior authorization, concurrent review, case management, disability review guidelines and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods and treatment protocols.
• May participate in business development, program development, and development of care integration models for increased care delivery efficiency and effectiveness.
• Participates in the administration of medical management programs to assure that network providers deliver and Plan members receive appropriate, high quality, cost effective care.
• Articulates Plan policies and procedures to providers and organizations and works to ensure effective implementation of policies and programs.
• Analyzes population-based reports to refine management activities, investigate and define variation, and ensure conformance to expected standards and targets.
• Investigates selected cases reported as deviating from accepted standards and takes appropriate actions.
• Actively interfaces with providers (hospitals, PPG's, IPA's) to improve health care outcomes, health care service utilization and costs.
• Analyzes member and population data to guide and manage program direction such as ensuring that members enroll in clinical programs indicated by their clinical need.
• Optimizes utilization of medical resources to maximize benefits for the member while supporting Health Net Plans and Health Net corporate initiatives.
• Assists in the analysis of performance data of physicians and hospitals and the development and implementation of a corrective action plan.
• Supports state regulatory relationships and may serve as the lead physician for state and federal medical management regulatory audits (i.e., NCQA, HEDIS, URAC).
• Actively supports Quality and Compliance to ensure that Health Net meets and exceeds medical management, regulatory, agency, and quality standards.
REQUIREMENTS:

Education:
Graduate of an accredited medical school; Doctorate degree in medicine.

Certification/License:
Board certification in an ABMS recognized specialty.

Experience:
• Minimum five years medical practice after completing residency-training requirements for board eligibility.
• Minimum three years medical management experience in a managed care environment.
Knowledge, Skills & Abilities:
• Demonstrated excellent interpersonal skills.
• Excellent oral and written communications skills.
• Current knowledge of industry standard medical management tools.
• Strong analytical and problem solving skills.
• Ability to work independently.
• Ability to set priorities and achieve objectives.
• Strong organizational skills.
• Must be able to work well with all levels in the organization, and participate as a member of a national medical management leadership team.
• Ability to operate PC-based software programs including proficiency in Word, Excel, PowerPoint, Access and MS Project.
• Travel required.
OR
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
For immediate consideration, click 'Apply to Job', locate this position by Job Number 08002499, scroll down, click on job title and apply online.

Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening. Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.

Posting Date: Sep 11 08