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ConnectiCare is a leading health plan in the state of Connecticut. A local company for more than 35 years, ConnectiCare has a full range of products and services for businesses, municipalities, individuals and those who are Medicare-eligible. By striving to make it easy for members to get the care they need, ConnectiCare leads the individual market in the state, and is ranked among the top commercial health plans in the nation, according to the National Committee for Quality Assurance. ConnectiCare is a subsidiary of EmblemHealth.
We’re looking for individuals who want to make a difference in the communities we serve. If you want to join a local team and help change the way health care is delivered, ConnectiCare is the place for you.
Summary of Job: To establish and improve medical operations and policy to support improved utilization results, clinical outcomes and medical trends.
- Improves the utilization of all medical services by contributing to the strategic direction for medical management programs including case management, prior authorization programs, disease management, pharmacy management, health risk assessments and medical economics.
- Provides Prior Authorization, Clinical Review, Inpatient Review and Grievance & Appeal services to Commercial and Medicare members as assigned.
- Supports case management activities as an integral member of the case management teams. Resolves case management questions and conflicts including interacting with attending physicians, physician advisors and IPA Medical Directors.
- Develops the skills and medical management capabilities of physician organizations and their medical directors. Cultivates cooperative relationships with their respective organizations. Works collaboratively to develop initiatives with designated integrated groups of physicians with a mutual focus on improving utilization, quality and cost outcomes
- Participates in the management of pharmacy programs. May act as a member of the Pharmacy and Therapeutic Committee.
- May participate on the Credentialing Committee and, in consultation with other leaders in Health Services, develop, refine and apply credentialing policy in accordance with NCQA standards.
- Acts as a member of the internal Quality Management Committee (QMC), to develop quality improvement policies and initiatives.
- Participates with Plan Managers as an integral part of the IPA/PHO Joint Operating Committee(s) (JOCs).
- Performs other related projects and duties as assigned.
- Licensed (current and active) Medical Doctor in state of CT
- Board certified (current) in area of expertise
- Primary care specialty or Internal Medicine specialty desirable
- Must possess at least ten years’ experience; it is recommended that at least two of which are in managed care
- Advanced degree desirable
- Knowledgeable about the healthcare industry and experienced with full risk managed care delivery systems
- Experience with the management of IPA, PHO and/or group practice models related to medical utilization, and/or resource management and quality assurance
- Computer literacy (Microsoft Word, Excel, and Access) desirable as it relates to the ability to manipulate and analyze data
Essential Job Requirements
- Primarily sedentary
- Must be able to use standard office equipment