The Office of Management and Enterprise Services (OMES) is a trusted, credible partner that empowers employees to provide valued business expertise allowing customers to focus on their missions across state government. OMES provides financial, property, purchasing, human resources and information technology services to all state agencies, and assists the Governor’s Office on budgetary policy matters.
Our mission is supporting our partners through unified business services. The OMES mission requires a highly-qualified workforce committed to making government run in the most efficient, innovative manner possible. Achieving that mission takes team-oriented, solutions-driven professionals who understand the importance of partnering to achieve success.
OMES is seeking a full-time Medical Director. This is an unclassified position in state government located in Oklahoma City, OK. OMES offers a comprehensive Benefits Package, including a generous benefit allowance to offset the cost of insurance premiums for employees and their eligible dependents. For more information about the benefit allowance [click here].The annual salary for this position is based on education and experience.
The OMES Medical Director oversees the Health Care Management Unit (HCMU), which provides all medical reviews in conjunction with contracted medical, dental, chiropractic, and physical therapy consultants. This individual examines medical reviews for additional life insurance (Evidence of Insurability reviews) and medical case management. The Medical Director also manages staff activities relating to utilization review, durable medical equipment, maternity care, case management, certification of home health, hospice management, and catastrophic case management.
• Provides medical oversight and determination of medical necessity of healthcare services provided to plan members, targeting improvements in efficiency and satisfaction for patients and providers.
• Participates in administrative decision-making; recommends and approves HCMU policies and procedures.
• Develops and implements medical policies within the bounds of the plan benefits and limitations.
• Reviews quality issues and focused reviews, and recommends corrective actions.
• Provides medical expertise for the case management activities of HCMU, including review of active cases for medical appropriateness or retrospective reviews of claims and appeals.
• Ensures the medical care covered by the plan meets the standards for acceptable medical care within the medical community; monitors changes in medical practice and standards of care.
• Attends or chairs committees such as compliance, TPA management, pharmacy and therapeutic, operations, senior staff, OEIBB board and subcommittees, and EGID executive committee.
• Directly involved in quality improvement activities, including focused reviews and recommending corrective actions to ensure quality, cost efficiency, and continuity of care.
• Utilizes data analysis to produce tools used to report, monitor, and improve case management/utilization management outcomes; reviews claims to detect/confirm fraud, waste and abuse.
• Develops and adjusts department goals, directs the principal operations and activities of the department, and supervises staff.
• Evaluates department operations and programs systematically and results used to make revisions to improve operating efficiency.
• Administers the state/OMES performance system with defined criteria and measurable standards.
• Develops department policies and procedures to ensure compliance with existing laws and other guidelines concerning group insurance programs.
• Makes recommendations for changes in agency policies as needed.
• Confers with other state agencies and industry authorities, and stays informed of changes and improvements in the health care industry.
• Represents HCMU both internally and in public regarding medical philosophy, policies, and related issues.
• Interfaces with other EGID departments to coordinate operation and programs.
• Participates in the functioning of the plan grievance procedures related to medical necessity, standard of care, cost shifting, and quality concerns; provides written recommendations of findings and outcomes.
• Monitors providers’ practice patterns and recommends corrective action.
• Interprets and advises staff and other interest groups on applicable laws and guidelines, and ensures that medical decisions are rendered by qualified medical personnel.
• Participates in member and provider appeals; attends/testifies at grievance hearings.
• Other tasks/duties as necessary.
Demonstrates knowledge of and supports mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality standards, and the code of ethical behavior.
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
Graduate of ACCME-recognized medical/osteopathic school; completed ACGME accredited residency; Board certified (with or without Maintenance of Certification) in specialty; ten years of practice experience; and current Oklahoma medical license, valid and unrestricted. Experience with health insurance administration/review, public health experience, or MPH are preferred.
Valued Skills and Experience
• Data analytic skills
• Effective interpersonal, oral and written communication abilities
• Outstanding presentation skills
• Personnel management
• Proficient with computers, Web-based programs and electronic medical records
Physical Demands and Work Environment
This position works in a comfortable office setting with a large percentage of the work day done on a computer and telephone. The noise level is usually mild. Ability to occasionally lift paper and office supplies and to perform job duties on a computer and telephone for 6-8 hours per day is necessary. Occasional travel may be required.
OMES is an Equal Opportunity Employer. Reasonable accommodation to individuals with disabilities may be provided upon request.