Responsible for assisting the Regional Medical Director in providing the means, structure, and environment to most effectively and efficaciously utilize the resources that are available to ensure that all enrolled members have access to appropriate medical care and are provided with opportunities for health promotion and health maintenance as an administration of their individual Health Plan benefits in conjunction with additional community resources identified as meeting member care needs.
• Reports to the Executive Director in the submarket with a dotted line to the Regional Medical Director.
• Manage a panel of patients, in specific geography with a balanced acuity. Participate in the call rotation.
• Two geographically separated offices:
o Act as the lead clinician by managing the IDT team along with the Executive Director and the Health Services Manager population health management. Supervise and instruct POD leaders and providers how to use the tools provided to lead effective Clinical Excellence and Panel Management IDT days such that the entire IDT team is focused on those patients who are, or at risk for being a high utilizer while continuing to successfully manage the less acute. Proactive patient team management along with operationally efficiency are keys to both preventing a preventable event along with quickly responding to one when they do occur.
o Responsible for the timely creation and posting of the submarket call schedule. Ideally published 60-90 days prior.
o Ensuring submarket team members adherence to Landmark daily huddles participation and protocol
o Along with the RMD, responsible for local plan relations along care collaboration with local PCP, delivery systems, HHA and hospice relations along with any others that could impact Landmark delivery of care in that submarket.
o Assists the RMD in establishing a Physician Advisory Board, leads this effort in the submarket and stands in for the RMD when unable to lead at the market level.
o Participates in submarket MLT meetings and other meetings as directed by the GM/ED/VP.
o Assists the RMD with administrative duties such as screening and interviewing provider candidates, performance reviews (QPU’s), approval of PTO, and creating and maintaining the call schedule amongst others.
o In coordination with RMD perform ride alongs and chart review of the providers who work in the submarket.
• Large market, single geography.
o Duties assigned by RMD which will include direct patient care, running effective IDT’s, assist with creating, publishing and participating in call schedule, ensure adherence to Landmark daily huddles participation and protocol
o Assists the RMD in managing and providing clinical lead to the POD’s assigned. Ensures communication across all market PODs are coordinated with MLT team.
o Stands in for RMD when not available for meetings within and outside of Landmark
o Assists in the development of material at the market level along with outside of Landmark such as PCP or delivery system meetings or plan JOC’s.
o Assists the RMD with administrative duties such as performance reviews (QPU’s), approval of PTO, creating and maintaining the call schedule amongst others.
o Other duties as assigned by the RMD
• Assist in the development of, documentation, implementation, and interpretation of local medical policies and procedures.
• At the direction of the RMD, oversees provider education, in-service training and provider orientation.
• Participates in Medical Director Conferences.
• Remain current in the knowledge of geriatrics, utilization management, quality management, managed care principals and new clinical developments and technologies.
• At the direction of the RMD interact with local attending physicians on application of the Landmark Health model and issues regarding medical practice.
• Assist in supporting the program within the community and assist in the development of local business opportunities for furthering the cause of the program.
• At the direction of the RMD assist in resolving conflicts between physicians and among physicians, members, and Landmark Health personnel.
• Meet/confer periodically via telephone or in person, with the Program Director, VP of Medical Services and other Landmark Health management regarding local issues including patient care plans and authorizations for service.
• Assist in providing Primary Care Physician Services to members if the member’s PCP is unavailable.
• Takes an active role in reviewing and discussing all items pertaining to Utilization Management.
• Assists in identifying requests that require additional review by specialist in a particular field and assists in establishing a review process with these specialists whenever necessary.
• Supports the Health Services staff in carrying out all UM activities.
• The RMD/ARMD is responsible for oversight of the Utilization Management process. This includes, but is not limited to the following:
• Referral request determinations
• Medical Necessity Denial of requests (with consultation with a specialist as needed)
• Acting as Chairperson of the Utilization Management Committee and the Quality Improvement Committee (if unable to attend, then Medical Director will arrange for his/her “designee” to perform this responsibility
• Review of policy and procedures
• Direct communication with individual providers regarding UM decisions
• At the direction of the RMD delegates direct intervention and decision-making regarding the approval and authorization of medical care and services to the appointed POD Leaders as needed within the structure of the established decision-making processes in support of eliminating potential conflict of interest.
• Participates in the continuous assessment and improvement of the quality of care provided to members through Quality Improvement activities.
• Participates in the surveillance of provider performance in conjunction with the Quality Improvement activities.
• Assists in the development, implementation, and evaluation of the Quality Improvement Program.
• At the direction of the RMD participates in the resolution of medically related grievances.
• Participates in provider recruitment activities related to the areas of network expansion, key to identifying additional providers/specialists needed for the network based on target population needs including providers and facilities in target population medical, mental health specialty services across all markets.
• At the direction of the RMD reviews and makes recommendations to the Credentialing Committee regarding the appointment and re-appointment of panel providers.
• Participates actively in the management of provider's contract status within the provider panel to ensure the delivery of quality-based health care while supporting the protections of the provider's rights as well as Landmark Health’s obligations for oversight and reporting.
• Participates actively in all Peer Review activities.
• Medical Doctor currently licensed to practice without restriction in the state of practice and has met or exceeded all the credentialing requirements of a provider within the provider panel.
• Current in the knowledge of geriatrics, utilization management, quality management, managed care principals and new clinical developments and technologies.
• Have significant experience in leading teams of physicians and mid-level providers in delivering high quality, cost effective care.
• Experience in recruiting and hiring medical talent along with continuous supervision of the medical care delivered.
• Ability to analyze staffing needs sufficient to care for the patient panel.
• Experience in coaching members of the health care team to provide excellent care or, if needed, determine deficiencies in care and formulate a plan for improvement.