• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. • Provide medical leadership for utilization management, cost containment, and medical quality improvement activities. • Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. • Support effective implementation of performance improvement initiatives for capitated providers. • Assist in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. • Provide medical expertise in the operation of approved quality improvement and utilization management programs. • Assist in the functioning of the physician committees including structure, processes, and membership. • Conduct regular rounds to assess and coordinate care for high-risk patients. • Collaborate with clinical teams, network providers, and medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. • Participate in provider network development and new market expansion as appropriate. • Assist in the development and implementation of physician education with respect to clinical issues and policies. • Identify utilization review studies and evaluate adverse trends in medical services and provider practice patterns. • Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice. • Interface with physicians and other providers to facilitate implementation of recommendations to improve utilization and healthcare quality. • Review claims involving complex or new services to determine medical necessity and appropriate payment. • Develop alliances with the provider community through the implementation of medical management programs. • Represent the business unit before various publics locally and nationally on medical philosophy, policies, and related issues as needed.