General Manager - Clinical Program - Insurance - BPO

Essential Duties and Responsibilities

The job holder will work with groups of Employees (EEs), and Functional Heads in addition to individuals across a variety of tasks:

- Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities in the execution of pre-service, concurrent review, retrospective review, quality assurance and other clinical programs.

- Ensures the clinical integrity of all MediCall medical programs

- Identifies opportunities for innovation, and drives its development to increase effectiveness and quality of the MediCall programs

- Actively participates in the quality management process through committee memberships (including but not limited to the Quality Management Committee) and identification of opportunities for improvement. Such QMC responsibilities are:

1. Provides guidance on the general Structure, Purpose, Scope, Objectives, Policies and Procedures of the QMP priorities and activities and QIPs.

2. Ensures that QMP activities and QIPs are established, implemented and maintained and its effectiveness is continuously monitored and improved in accordance with Company and URAC standards.

3. Approves proposed QMP and its activity and QIP to undertake.

Monitors utilization management quality auditing results including physician review vendors and provides guidance for quality process improvement

- Provides guidance on existing policies/procedures and drives development of new policies as needed by clients

- Participates in review and assesses SOPs at least annually to ensure that all applicable accreditation, state and federal requirements are met.

- Provides final approval of clinical SOPs

- Conducts telephonic, electronic or personal physician discussions with clinical staff and practitioners in the field

- Ensures that qualified clinical staff are held accountable for decisions affecting consumers

- Functions as a clinical and management resource and consultant to other areas of the company

- Participates in the development of training programs

- Collaborates with workgroups to resolve issues that impact internal and external customers

- Manages and resolves escalated complaints

- May attend client and prospective client meetings telephonically or onsite as requested by Senior Management

- May chair or serve on other company committees as assigned.

- Performs other duties as may be assigned.