Medical Consultant

• Set “tone from the top”: Provider members with clear and quick communication about their claim requests in a professional manner that balances medical outcomes with fiduciary responsibility in managing the payor (client company) funds.
• Set Standards : As the Medical Director for SIMPLeTPA, he/she is primarily responsible to set and consistently review overall managed care standards for claims administration which include, but is not limited to:
  • Advise and Sign off on appropriateness of standard medical protocols (e.g. appropriate test and treatment plans for given conditions)
  • Advise and Sign off on appropriate “usual and customary” fees and/or reimbursement levels associated with specific treatments and/or Diagnostic Related Group (DRG) set costs
  • [The above will require the Medical Director to be have significant interaction with potential SIMPLeTPA Healthcare Network Providers to assure an adequate number of providers will agree to the SIMPLeTPA Terms of Service.]
• Support Efficient Outcomes for SIMPLeTPA Employers : Monitor and evaluate claims data for SIMPLeTPA Employers to provide advice on how to generate the best possible medical outcomes given the Employer’s budget for employee healthcare. This would include, but not limited to:
  • Recommending and monitoring specific treatment plans for chronic cases
  • Recommending and supporting implementation of health and well being programs that will improve overall health conditions of employees (e.g. Health and Well Being Programs, Employee Early Screening Progarms and other preventive and educational programs designed to enhance overall employee health that will reduce overall long-term cost of medical treatments)
  • Work with Employer mandated on-site health care providers to assure proper health care administration process (e.g. initial consultation and specialist referral processes)
• Provide ad hoc Patient Review : Work with and review complex medical cases in connection with the Members attending physician to determine the most effective medical treatment plan. Cases will be managed as part of Claims and Customer Service team to monitor and approve appropriate treatments and appropriate coverage levels in line with the Employers designated plan. The would include, but not limited to:
  • Approving/Denying Guarantee of Payment (GOPs) which is a letters of authorization for treatments in which part or all of the payment will be guaranteed upon approval.
  • Registering and being approved by SIMPLeTPA to be its legal medical representative to receive and review confidential member data necessary for full assessment of their medical condition.
• Support day-to-day operational functions:
  • Act as the physician of record to receive and evaluate patients medical records.
  • Liaise with patients and other medical professionals when required to approve appropriate a patient’s specific course of treatment.
  • With team support, monitor patients progress to know patients needs are being met.

SERVICES TO MARKET

• Adviser to SIMPLeTPA employers on efficient health care management
• Leader in healthcare system in efficient healthcare management

DUTIES AND RESPONSIBILITIES

• Support the design, implementation and continuous management of the rapid claims management system – including gathering and monitoring claims costs on a treatment and/or DRG basis. The role involves keeping up on trends and innovation in the healthcare industry that is delivering better healthcare outcomes at the best price.
• Work with insurance and healthcare partners to assure proper alignment and coordination on all claims processing where applicable
• Work as a “teammate” with our Sales and Network Provider teams to support issues that can arise when determining appropriate treatments and reimbursement rates; particularly aligning with major healthcare provider’s minimum required reimbursement levels
• Work as a “teammate” with the Claims and Customer Service team manage the set the Standard Operating Procedures (SOPs) for claims management (particularly in cases requiring expert medical knowledge).
• Identify and solicit expert medical advice within the healthcare industry to provide SME expertise for cases that fall outside the Medical Directors experience (the Medical Director is NOT expected to be an SME in all fields)
• Work with Claims and CS teammates to monitor and audit claim trends for potential fraud or overutilization; explore alternate and preventative medical treatments/protocols
• Work as key team member for building out the claims management platform to deliver customer-centric solutions to ease the healthcare process and mitigate any surprises in the claims/GOP processes
• Address and act as key decision maker with customers, medical providers or other interested parties when dealing with special or challenging medical conditions and/or treatment decisions
• Continuously update and maintain databases required to support the claims adjudication system (includes both list of preferred providers as well as the industry standard “usual and customary” costs and protocols for specific conditions
• Draft and maintain appropriate risk management guidelines and policies for medical decision making, appeal processes and other related issues for both SIMPLeTPA self-insured plans as well as plans provided in coordination with other insurance companies
• Manages the workload balance, including acting as a backup as required
• Develops tools and reports for claims and customer service performance as needed

QUALIFICATIONS

• Board certified physician eligible to receive and review medical records as the legal medical representative of SIMPLeTPA
• Demonstrated experience working with medical providers to resolve difficult claim cases
• History of innovative, creative and driven worker
• Excellent written and verbal communication skills
• Knowledgeable on digital enterprise workspace productivity tools (e.g. excel, word and ppt or equivalent); experience working with data analytic tools highly appreciated

WORK ENVIRONMENT

• Position will be offered on a contract and/or full-time basis depending on the candidate
• SIMPLeTPA prefers a flexible face to face working environment, but will accommodate work from home schedules where performance can be enhanced

ACKNOWLEDGEMENT AND ACCEPTANCE

I certify that I have read and I understand the duties and responsibilities and other features and dimensions of the job, as specified and stated in this Job Description. I accept these duties and responsibilities and agree to maximize and optimize existing competencies and develop new competencies to achieve the different performance and competency standards.