The Medical Director & Healthcare Operations Advisor plays a crucial role in overseeing healthcare management, including but not limited to utilization management, clinical pathways, and clinical quality management.

The role involves maintaining and developing relationships with the company’s clients and healthcare provider network(s). The ideal candidate will have strong expertise in the application of clinical pathways to utilization management, disease state management, managed care products and other cost containment programs resulting in the optimization of healthcare resources and improvement of health outcomes.

1) Utilization Management

• Contribute to the development, enhancement and management of the company’s utilization management and clinical quality management plans.
• Direct or matrix oversight of the utilization management function and revenue lines.
• Ensure team provides timely and high-quality assessments to key external stakeholders. - Final authorizations / letter of guarantee within 45 minutes of receipt of complete documentation
• Targeted concurrent review based on high-cost diagnoses and healthcare providers (or outliers) - Simple, non-complicated authorization completed within 2 hours of request
• Complicated authorizations issued within 24 hours of request.
• Review of care treatment plans and claims for medically necessary and medically appropriate levels of care.

2) Quality Management

• Develop a bridge for the orientation of Inova Care’s and/or market’s procedure coding logic and clinical pathway strategy for providers.
• Ensure adherence to utilization management protocols, including monitoring UM and Claim staff performance to ensure that goals and objectives are met.
• Engage in other utilization and quality management activities supporting the company’s revenue and cost containment strategies.

3) Life, Accident and Health Medical Claims Management

• Provide input and advice regarding medical claims to ensure accuracy and compliance with medical necessity and appropriateness.
• Work closely with the claims team to review and manage complex claims, providing medical expertise and guidance.
• Coordinate with client and/or client’s TPA regarding UM decisions (when Inova is not performing claims management functions).

4) Other Responsibilities

• Exporting and adapting elements of the US managed care industry (or other established and proven markets) for implementation to establish Best Practices in Asia to improve access to care while ensuring optimal outcomes and controlling healthcare costs.
• Develop of modular utilization management solutions that can be sold to clients on a standalone basis.
• Develop and maintain strong clinical and administrative alliances within the provider community to drive operational and performance results.
• Develop new and expanded capabilities for additional care settings leveraging digital technology.
• Serve as chief point of escalation for clients, network healthcare providers and internal UM nurses and care coordinators resources for healthcare questions and concerns.
• Other tasks and projects that contribute to Inova meeting or exceeding its business goals and objectives.
• Develop of modular utilization management solutions that can be sold to clients on a standalone basis.
• Develop and maintain strong clinical and administrative alliances within the provider community to drive operational and performance results.
• Develop new and expanded capabilities for additional care settings leveraging digital technology.
• Serve as chief point of escalation for clients, network healthcare providers and internal UM nurses and care coordinators resources for healthcare questions and concerns.
• Other tasks and projects that contribute to Inova meeting or exceeding its business goals and objectives. 

• Medical degree (MD or DO) with a valid medical license.
• Completion of residency training in Internal Medicine or Family Medicine.
• A minimum of three years of clinical experience.
• At least three years of experience in managed care, utilization management, case management, clinical quality management, accident and health claims management, and/or other clinical decision-making processes.
• Strong background in developing and managing clinical pathways, with proficiency in using InterQual, MCG, medical policies, and other clinical guidelines, as well as managing relationships with healthcare providers.
• Excellent communication and interpersonal skills.
• Ability to work both independently and collaboratively within a team.
• Strong organizational and reporting skills.