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•$156k Per Year Medical Director (43921) . .

Neighborhood Health Plan of Rhode Island

Occupation:

Medical and Health Services Managers

Location:

Smithfield, RI

•02917

Job Type:

Full Time (30 Hours or More)

Posted:

05/28/2026

Positions available: 1

Source:

FileImport

•Neighborhood Health Plan of Rhode Island

Web Site:

www.paycomonline.net

Expires:

10/26/2026

Job #: 173362

Job Requirements and Properties

Help for Job Requirements and Properties. Opens a new window. Work Onsite

Full Time Schedule

Full Time

Job Description

Help for Job Description. Opens a new window. Description

The Medical Director is to provide clinical leadership and consultation to the Plan's various departments with the goal of promoting clinical excellence, quality care in our provider network, as well as maximizing member access to care and satisfaction in health care services. Duties and Responsibilities Responsibilities include, but are not limited to the following: Work closely with the CMO to establish a clinical strategy to meet the medical management PMPM performance targets while promoting quality healthcare for the plan's members. Oversee the Associate Medical Directors and Medical Consultants to ensure that all departments of the plan have access to physician input. This includes providing clinical expertise during established rounds, and on an as needed basis for clinical programs including case management, disease management or any other clinically based programs. Provide oversight of the scheduling, payroll, and budget for the Medical Director Department. Ensure that clinical expertise is maintained in the Medical Review process by establishing processes and target expectations for inpatient and outpatient utilization review. These activities include... Serve as Chair/ oversight of the Pharmacy and Therapeutics committee. Serve as Chair of the Utilization Management Committee. This includes ultimate oversight of Clinical Medical Policies. Provide oversight to the AMD running the Clinical Affairs Committee. Provide oversight and input regarding benefit guidelines. Perform any review of pharmacy or medical requests for non-covered services/products. Ensure that all regulatory expectations of the review processes are followed by coordination with the Compliance and GAU departments. Provide full support for quality initiatives. Oversight of the Quality Assurance Committee process including review of cases with the staffurse assisting with the review. Participation in the NCQA Readiness, D-SNP Quality Committee, & Medicaid and Commercial Quality Committee Provide management oversight of the Credentialing Team and Health @ Home Team. Provide or facilitate clinical expertise for the following functions: Credentialing activities, including approval and re-approval processes. Fraud, waste and abuse activities. Behavioral Health management with oversight of the BH medical director. Care Management Work closely with the Pharmacy team to participate in the oversight of the plan's PBM. Participate in any needed preparation and presentation of regulatory and accreditation review. This work includes representing Neighborhood at any State Fair hearings or Administrative Law Judge activities. Engage in on-going performance management of staff including coaching, mentoring, development, Training and succession planning to include hiring and termination decisions. In coordination with the CMO, represent Neighborhood in internal and external meetings and forums with Providers, vendors, and regulators. This includes the management of the interactions with the regulatory bodies (OHIC/EOHHS/CMS) as well as statewide stakeholders such as

CTC, PCMH

Kids. Active participation on the Medical Cost Action Committee by developing and sponsoring the initiation of measures to control medical cost. Perform other duties as assigned Corporate Compliance Responsibility

•As an essential function, the Medical Director is responsible for complying with Neighborhood's Corporate Compliance Program, Standards ...For full information see follow application link.

Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.