• Responsible for becoming familiar with the standards of practice for assisted living • Achieving a proficient level of competency within all departments of the Community • Assisting in the overall operation of the Community while completing the required training hours for certification or licensure

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description In support of the CMO, the Associate Medical Director is responsible for the administration of procedures, protocols, and standards regarding the efficiency and quality of the health care delivered to Network Health (NH) members. This individual will be chair of at least 3 committees related to quality and accreditation. Location: - Candidates must reside in the state of Wisconsin for consideration. - This position is eligible to work at your home office (reliable internet is required). - Travel is required occasionally for the position. Hours: - 1.0 FTE, 40 hours per week, 8am - 5pm Monday through Friday. - Weekend coverage required on a rotational basis. Job Responsibilities: - Assist the CMO with monitoring availability, appropriateness, and necessity of care rendered by participating providers and by out-of-plan providers. - Participate in oversight and clinical decision making of the UM program, including but not limited to rendering denial determinations for services not considered medically necessary or experimental/investigation/unproven in accordance with regulatory and quality standards. - Contribute to the development of quality care guidelines, internal peer review procedures, and the evaluation of medical care evaluation studies under the NHP quality assurance programs. - In coordination with the CMO and Directors of Health Management and QI and Disease Management, share responsibility for the development and continued evaluation of utilization review and quality assessment processes. - Provide medical consultation as requested for: - Medical/legal issues - Member grievance procedures - Development and implementation of new benefit packages and the interpretation of covered benefits in NHP contracts - Medical issues related to contract negotiations with health care providers - Determining if services to members/enrollees meet medical criteria - Promote positive relationship between NHP and medical community. - Serve as liaison between NHP and providers regarding matters of medical policy and medical administration. - Serve as spokesperson for NHP in the medical community and maintains appropriate contact with professional health care organizations. - Participates in the ongoing recruitment of plan physicians. - Respond to physicians and other provider inquiries and complaints within established guidelines of the Executive Committee and Board of Directors. - Assist in the development of appropriate medical guidelines and parameters for claims review. - Assist in the training of NHP staff on matters relating to medical guidelines. - Oversight responsibility for monitoring and evaluating Medicare Special Needs Plan Model of Care effectiveness. - Perform second level review of provider appeals and disputes. - Serve on committees as coordinated with the CMO. - Assist in strategic planning targeted towards plan growth initiatives. Qualifications - Doctor of Medicine (MD or DO), licensed in the state of Wisconsin without restriction. - Member in good standing of the local medical community. - An active practitioner of medicine in the NHP service areas. - Must possess a thorough knowledge of the health professional and facilities and standards of practice of medicine in NHP’s service area. - Must possess sufficient medical experience and other experience, including knowledge of the Medicare program, to review organization determinations involving medical necessity. - Board certified in an ABMS medical specialty required. Company Description Network Health is an Equal Opportunity Employer.

• Design, implement, and oversee comprehensive clinical quality assurance programs for in-home care delivery • Establish and monitor key performance indicators (KPIs) and quality metrics for clinical services • Ensure compliance with HEDIS quality measures and support health plan partners in achieving quality targets • Lead root cause analysis and corrective action planning for quality incidents • Develop and maintain clinical protocols, standard operating procedures, and best practices • Collaborate with the Chief Medical Officer and clinical leadership on quality improvement initiatives • Oversee patient safety programs and incident reporting systems • Design and implement comprehensive onboarding and continuing education programs for all clinical team members • Develop competency assessment frameworks and ensure all clinicians meet performance standards • Oversee the creation of engaging training materials, protocols, and resources for both technical and soft skills • Lead train-the-trainer programs to build internal training capacity across regions • Evaluate training effectiveness through assessments, audits, and performance data • Partner with People/HR teams and clinical leadership on clinical workforce development initiatives • Stay current on best practices in adult learning and clinical education • Build and maintain a robust quality assurance and initiatives program with clear KPIs and reporting • Ensure all clinical operations comply with state and federal regulations, including OSHA, CLIA, and HIPAA • Maintain relationships with relevant regulatory bodies and manage audit processes • Partner closely with credentialing and compliance officer to ensure adherence to scope of practice requirements across different states • Partner with Operations, Product, and Technology teams to optimize clinical workflows • Collaborate with Customer Success teams to address partner needs around quality and training • Work with Data and Analytics teams to leverage insights for quality improvement • Support Business Development efforts with clinical expertise and quality metrics • Serve as clinical quality subject matter expert for internal and external stakeholders • Responsible for performance of quality and training teams • Build and manage a high-performing clinical quality and training team • Foster a culture of continuous improvement, learning, and clinical excellence • Provide mentorship and professional development opportunities for team members • Establish clear goals, metrics, and accountability frameworks

• review of medical authorizations • determines the medical necessity of given service, level of care, or medical item/supply • conduct clinical reviews of care received by members in assigned LTSS Medicaid states • provide medical interpretation and determinations whether services are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and contracts • support and collaborate with other team members, other departments, Humana colleagues and the Regional VP Health Services • work in a structured environment with expectations for consistency in thinking and authorship • exercise independence in meeting departmental expectations and compliance timelines