ProgenyHealth is a leading provider of care management solutions for premature and medically complex newborns. We partner with health plans and their neonatal providers to work collaboratively in developing a plan of care specific to the needs of each child - from admission to the intensive care nursery until they are safely transitioned from the hospital, through the first year of life. Our program promotes appropriate utilization, improves access, educates family members, reduces costs, and improves outcomes.

Job Role

The Medical Director will report to the Lead Medical Director and will support the ProgenyHealth Medical Management program by conducting medical necessity review on inpatient, outpatient, pharmaceutical, DME, new technology and home care requests, as needed, and to complete the cases in the required timeframes to be in compliance with URAC & NCQA standards.

Responsibilities Include:

• Rounding with ProgenyHealth clinical care nurses and case managers to offer recommendations, support and clinical expertise to assist with concurrent review of cases for medical necessity based on criteria, guidelines and clinical judgment.
• Conducting medical necessity reviews on inpatient, outpatient, pharmaceutical, DME, new technology and home care requests, as needed.
• Proactively call attending physicians, as needed, to discuss and clarify medical/surgical plans of care and any discharge planning needs, or to make recommendations supporting evidence based best practices when variations in care are identified.
• Responding to requests for a peer to peer conversation or other medical management discussion from/with an attending or ordering provider to discuss a case, determination, or other matter.
• Identifying and addressing Quality of Care issues; participating in Quality Improvement programs
• Ensuring fair and consistent decision making through the use of approved criteria and guidelines, and providing guidance; and is responsible for all clinical aspects of Medical Management.
• Preparing and delivering clinical educational presentations to staff when requested.
• Striving to exceed customer expectations and serving to support the desired image of excellence of service.

Qualifications

• MD/DO degree and Board Certified in Neonatal-Perinatal or Pediatric medicine required
• Minimum of three years clinical practice experience in Neonatal or Pediatric medicine after residency
• A minimum of 1 year experience in a managed care environment, or relevant hospital experience as a physician advisor or medical director, preferred.
• Must be organized, self-motivated and willing to learn multiple tasks.
• Must have excellent computer skills and be proficient in Microsoft Office
• Active, unrestricted license to practice medicine
• This is a full-time position with work hours in the Pacific /Mountain time zones, approximately 8:30am - 5:00pm

Benefits/Culture

Our team is our most important asset. some of the benefits we offer our team are:

• 401K with company match
• Medical and dental benefits
• Long Term Disability
• Paid Time Off
• Business Casual Work environment
• Team orientated events throughout the year