- Oversee Company medical programs and resources, directing activities, project initiation with other departments, divisions, and external partners.
- Work collaborate with other functional areas that interface with medical management including provider relations, sales, healthcare delivery and national medical services to achieve the business goals of the company.
- Apply data analytics, predictive models, and industry trends to develop utilization management strategies.
- Improve quality and enhance capabilities of Company Medical Team.
- Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities.
- Act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical service program by the clinical team.
Medical and utilization management
- Develop and implement initiatives focused on claim management and healthcare provider management.
- Collaborate with associates to provide medical expertise during the investigation, evaluation, and appropriate resolution of individual insurance claims.
- Review insurance claims and evaluate the appropriateness and cost-effectiveness of the medical treatment and services
- Perform mortality and morbidity risk assessments as well as assist in projecting medical costs for insurance claims reserving and settlement analysis.