DVHA Medical Director RFP 03410-245-27.docx

This is a Request for Proposals (RFP) issued by the Department of Vermont Health Access (DVHA) for Medicaid Physician Review and Consulting Services. The RFP solicits proposals from actively licensed physicians to provide medical oversight and clinical consultation services to support DVHA's Medicaid program operations. Primary responsibilities include reviewing prior authorization requests for medical necessity determinations, supporting the Clinical Services Team in evaluating clinical information, reviewing and adopting clinical guidelines, assessing non-emergent medical transportation requests, assisting nurse case managers with patient condition management questions, participating in monthly case reviews, conducting peer-to-peer discussions with providers regarding coverage determinations, and participating in appeals and fair hearings as needed. The position requires a maximum time commitment of ten hours per week on an as-needed basis, with scheduling to be mutually agreed upon by the contractor, the State Clinical Services Team Director, and the State's Chief Medical Officer.

Candidates must hold an M.D. or D.O. degree and have completed a minimum of one-year primary care or general medicine internship, with board certification in an ABMS-approved specialty required. The contract operates within a Medicaid Managed Care environment focused on ensuring medical necessity and cost efficiency while serving as stewards of public funds rather than limiting access to care or generating profits. The RFP emphasizes that the physician will work collaboratively with DVHA's existing clinical infrastructure, including the Vermont Chronic Care Initiative, and participate in quality improvement activities as designated by the department.