Medical Director – LTSS

Responsibilities

• Responsible for utilization management across the Kansas Medicaid population, focusing on long-term services and supports (LTSS)
• Coordinates care and benefits, collaborating with internal teams, and engaging with external stakeholders such as the state and providers
• Supports clinicians to ensure timely and consistent responses to members and providers
• Provides guidance for clinical operational aspects of a program
• Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations
• May conduct peer-to-peer clinical appeal case reviews
• Serves as a resource and consultant for other areas of the company
• Interprets medical policies and clinical guidelines
• Develops and proposes new medical policies based on changes in healthcare
• Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes
• Identifies and develops opportunities for innovation to increase effectiveness and quality

Requirements

• Requires MD or DO and Board certification approved by American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)
• Must possess an active unrestricted medical license to practice medicine or a health profession
• Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background
• For Health Solutions and Carelon organizations, minimum of 5 years of experience providing health care is required
• Preferred: Ability to obtain a Kansas medical license
• Preferred: Board certification in any Primary Care Specialty with Geriatrics experience
• Preferred: Five years of experience in directing health care services for frail elderly or individuals with physical, intellectual, and/or developmental disabilities