Martin’s Point Health Care

The VP Medical Director manages Health Plan Medical Directors to provide clinical support for utilization, care, and quality management teams. They drive the development of evidence-based programs to manage medical expenses, quality outcomes, and utilization trends.

Oversee health plan claims administration and payment integrity functions to ensure payment accuracy and regulatory compliance. Manage vendor relationships, optimize system processing, and develop provider payment methodologies and fee schedules.

Perform in-depth financial analyses, including ROI and business case evaluations, to support strategic organizational decisions. Collaborate with leadership to develop forecasting tools and monitor monthly financial performance to drive margin improvements.

The Utilization Review Nurse is responsible for conducting prior authorization, concurrent, and retrospective reviews to ensure cost-efficient medical outcomes. They coordinate transitions of care, manage claims disputes, and collaborate with providers to ensure members receive the appropriate level of care.

The Utilization Review Nurse ensures high-quality, cost-efficient medical outcomes for enrollees needing inpatient/outpatient authorizations. Responsibilities include reviewing prior authorization requests, coordinating transitions of care, and managing health care within compliance regulations.