Medical Director Utilization Management

Responsibilities

• Serves as medical advisor and manager for all clinically related activities
• Ensures that the organization’s medical policies and procedures adhere to contractual obligations
• Performs clinical case reviews in conjunction with the Medical Excellence Department
• Demonstrates knowledge of prescribed and established medical procedures and practices
• Maintains familiarity with federal, state, and local medical and clinical operations regulations
• Provides leadership in developing and implementing medical policy related to health management, compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations
• Manages day-to-day operations and monitors the integration and processing of members to optimize the appropriate use of behavioral and physical health services
• Participates with Quality Improvement and Medical Excellence in identifying and analyzing medical and behavioral health information to develop interventions to improve the clinical effectiveness of medical management strategies
• Works closely with a multidisciplinary team to ensure behavioral health management and quality management programs meet contractual obligations
• Trains staff on medical issues and provides consultation to staff as appropriate
• Affords Care Managers in assessing members’ needs for case management services and attends meetings and monthly rounds as scheduled
• Collaborates with the integrated case management team during scheduled meetings and informally as needed
• Thoroughly documents all care coordination activity in the member’s medical record in the electronic case management documentation system

Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) required
• Master of Health Administration (MHA), Master of Public Health (MPH), or Master of Business Administration (MBA) in Healthcare Management preferred
• A minimum of three years of utilization management or appeals experience in a Medicaid, Medicare, and/or dual eligible
• A minimum of five years of clinical practice experience required in family medicine, pediatrics, internal medicine, surgery, neonatology, or physiatry
• Proficiency utilizing MS Office Suite, internet applications, and electronic medical record and documentation programs

Qualifications

• Licensure: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) with a Pennsylvania medical license that is active and in good standing. Additional medical licensure is required in all states where AmeriHealth Caritas has a line of business.

Skills

• Knowledge of medical procedures and practices
• Familiarity with regulatory guidelines
• Leadership in developing and implementing medical policies
• Ability to manage day-to-day operations
• Experience with clinical case reviews
• Proficiency in MS Office Suite and electronic medical record systems

Benefits

• Flexible work solutions including remote options
• Competitive pay
• Paid time off including holidays and volunteer events
• Health insurance coverage for you and your dependents on Day 1
• Tuition reimbursement