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MEDICAL DIRECTOR, PRIMAHEALTH

Job Title: MEDICAL DIRECTOR, PRIMAHEALTH
Job Code: 5248
FLSA: E
Job Level: L2
Revised Date: 06/13/2005
Supervisory Responsibility: Yes

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General Description of the Job Class

Provide professional medical direction services to the PrimaHealth Independent Practice Association (IPA).

Duties and Responsibilities of this Level

Provide professional medical direction services to PrimaHealth including, but not limited to, implementing, maintaining and refining approved quality assurance/utilization management programs; keep abreast of and ensure compliance with federal and NCQA regulations for managed care programs.

Manage the functions of the IPA Quality Assurance/Utilization Review Committees.

Identify utilization review studies and evaluate adverse trends in hospital utilization, unusual provider practice patterns, adequacy of benefit/payment components and comparative differences in utilization trends by HMO and PPO providers.

Work collaboratively with member services, medical services, provider relations and the executive director to prepare, deliver and encourage implementation of recommendations to provider member for actions which would improve utilization.

Participate in the review and assessment, and provide advice on, complex, controversial and/or unique claims which are outside the realm of medical policy; solicit and evaluate advice of outside medical consultants and physicians with respect to complex or controversial claims or experimental and innovative techniques.

Provide medical expertise with respect to planning and establishing goals and policies to improve medical management.

Participate in provider network development and new market expansion as appropriate; participate in the review, assessment and negotiation of provider contracts as appropriate. Collaborate with the Executive Director in the development and implementation of physician education.

Represent the IPA on ad hoc committees as appropriate; interface with the provider community regarding medical review, utilization review and quality assurance issues and concerns.

Participate in network development, contracting, and credentialing in local and regional markets.

Perform other related duties incidental to the work described herein.

Required Qualifications at this Level

Education

Work requires a Medical degree from an accredited University. Board certification in primary specialty is also required.

Experience

Five years of clinical practice and experience in the development and management of utilization review and quality assurance programs.

OR AN EQUIVALENT COMBINATION OF RELEVANT EDUCATION AND/OR EXPERIENCE

Degrees, Licensure, and/or Certification

N/A

Knowledge, Skills, and Abilities

N/A

Distinguishing Characteristics of this Level

N/A


The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.


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Essential Physical Job Functions

Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.