• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit • Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities • Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making • Supports effective implementation of performance improvement initiatives for capitated providers • Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members • Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements • Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership • Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes • Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals • Participates in provider network development and new market expansion as appropriate • Assists in the development and implementation of physician education with respect to clinical issues and policies • Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components • Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care • Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality • Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment • Develops alliances with the provider community through the development and implementation of the medical management programs • May represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues • Represents the business unit at appropriate state committees and other ad hoc committees • May be required to work weekends and holidays in support of business operations, as needed