This is an exceptional opportunity with our top tier managed
care client to support the Medicaid Clinical Operations
business in the state of West Virginia.
The ideal candidate will be responsible for the
administration of medical services for company health plans
including the overall medical policies of the business unit to
ensure the appropriate and most cost-effective medical care is
Interprets existing policies and develops new policies based on
changes in the healthcare or medical arena.
Leads, develops, directs and implements clinical and
non-clinical activities that impact health care quality cost and
Identifies and develops opportunities for innovation to increase
effectiveness and quality.
Serves as a resource and consultant to other areas of the
company, may chair or serve on company committees, may be required
to represent the company to external entities and/or serve on
external committees, conduct peer clinical and/or appeal case
reviews and peer to peer clinical reviews with attending physicians
or other ordering providers to discuss review determinations,
provides guidance for clinical operational aspects of the
Supports the medical management staff ensuring timely and
consistent responses to members and providers.
Requires M.D. or D.O.;
Board certification approved by the American Board of Medical
Specialties required where applicable to duties being performed
(Internal Medicine or Family Medicine or double-boarded Internal
Medicine/Pediatrics strongly preferred).
Must possess an active unrestricted medical license to practice
medicine or a health profession in the state of WV or Must be able
to obtain a WV license (expenses will be reimbursed).
West Virginia resident highly preferred.
5 years of clinical experience or any combination of education
and experience, which would provide an equivalent background.
Requires strong oral, written and interpersonal communication
skills, problem-solving skills, facilitation skills, and analytical
Managed care experience highly preferred.
Proficiency with MS products (Word, Excel) and familiarity with
large electronic system (for example EMRs) required.
Contact information :