Medical Director Utilization Management
for sections like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections if posting has real specific content. We need to parse the job posting.
Let's extract content:
Job Summary: description of role.
Work Arrangement: Fully remote; must be willing to work rotational weekend and holidays.
Responsibilities: list of bullet-like sentences.
Education And Experience: requirements.
Licensure: requirements.
Our Comprehensive Benefits Package: description.
Also mention "Competitive pay" but not specific numbers. The rule: do NOT create Pay/Schedule/Benefits sections unless posting actually states them. Benefits: they list benefits (flexible work solutions, competitive pay, PTO, health insurance, 401(k), tuition reimbursement, etc). So we can include Benefits section.
Pay: they say "Competitive pay" but no specific amount. The rule says never emit a heading followed by filler/placeholder text (e.g., "commensurate with experience", "not specified", "N/A", "varies", "TBD"). "Competitive pay" is vague but maybe considered placeholder? It's not a specific number. The instruction: "never create Pay/Schedule/Benefits sections unless the posting actually states them." It says "states them" meaning actual content, not placeholder. "Competitive pay" is still a statement but vague. Might be considered filler? The examples include "commensurate with experience", "not specified", "N/A", "varies", "TBD". "Competitive pay" is similar to "commensurate with experience". I'd avoid Pay section.
Schedule: they mention "must be willing to work rotational weekend and holidays." That's schedule info. Could be considered schedule content. The rule: include Schedule section only if posting has real specific content. "rotational weekend and holidays" is specific enough? It's not a placeholder like "varies". I'd include Schedule.
Benefits: they list specific benefits: flexible work solutions including remote options, hybrid work schedules, Competitive pay (maybe skip), Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more. Also mention internet reimbursement etc. So we can include Benefits.
About the role: we have Job Summary and Work Arrangement maybe combined. Could be "About the role" section.
Responsibilities: we have list.
Requirements/Qualifications: Education And Experience and Licensure could be combined into Requirements or Qualifications. We need to decide headings. Use for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). We can choose either Requirements or Qualifications. Probably combine education/experience and licensure into Requirements. Skills maybe not explicitly listed; we have proficiency MS Office, etc. That could be Skills. But we could also put under Requirements. The instruction: prefer a few substantive sections over many thin ones. So we could have About the role, Responsibilities, Requirements, Benefits, Schedule. That's five sections.
We must not repeat job title as heading. No Job ID.
We must remove boilerplate: cookie/navigation/legal/EEO etc. Not present.
We must preserve all substantive information; do not invent or summarize away detail. So we need to include all details from the posting.
We need to format lists with - for any list of duties/requirements/benefits. Use
for prose.
We need to ensure we include all specifics: job summary paragraphs, work arrangement, responsibilities bullet list, education/experience bullet list, licensure bullet list, benefits list, schedule note.
We must not create sections with filler. Avoid Pay.
Let's extract details precisely.
Job Summary paragraph:
"In this role, you will lead the operational areas of the Utilization Management (UM) program including prospective, concurrent, and retrospective reviews. As a Medical Director, UM you ensure all patient care decisions and referrals are medically appropriate by using national and local criteria. Our Medical Directors, UM help develop and implement medical policies, procedures, and clinical guidelines aligned with contractual obligations and regulatory guidelines. They partner with Quality Improvement teams to analyze utilization trends and develop interventions to improve clinical effectiveness. Medical Directors, UM also serve as a key point of contact for physicians and providers, conducting peer-to-peer discussions to facilitate collaborative care and resolve issues. In addition, you will collaborate with Corporate Medical Directors, our Utilization and Case Management RNs and staff, and the Vice President, Medical Affairs."
Work Arrangement:
"Fully remote; must be willing to work rotational weekend and holidays."
Responsibilities list (looks like a paragraph with many sentences separated by line breaks? We'll treat each sentence as a bullet item). Let's list:
- Ensures quality and clinically sound services for all enrollees through associates and providers.
- 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.
- Work closely with a multidisciplinary team to ensure behavioral health management and quality management programs meet contractual obligations
- Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff
- Trains staff on medical issues and provides consultation to staff as appropriate
- Assists 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
Education And Experience:
- 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
Licensure:
- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) that is active and in good standing.
- Must be able to obtain Pennsylvania license within 120 days of hire.
- Additional medical licensure is required in all states where AmeriHealth Caritas has a line of business.
- The application is expected to be initiated within 30 days of hire.
- Candidates must be board certified in their specialty.
- Must be clear of any sanctions by the applicable state or the Office of the Inspector General.
- Must not be prohibited from participating in any Federally or state-funded healthcare programs.
Benefits:
- Flexible work solutions including remote options, hybrid work schedules,
- Competitive pay,
- Paid time off including holidays and volunteer events,
- Health insurance coverage for you and your dependents on Day 1,
- 401(k)
- Tuition reimbursement and more.
- For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities.
- A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required.
- Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
Schedule note: "must be willing to work rotational weekend and holidays." Already in Work Arrangement. Could be separate Schedule section: "Rotational weekend and holidays required."
But we already have Work Arrangement as prose maybe under About the role. However we need to include Schedule section if we want. The rule: include a section ONLY when posting has real specific content. The schedule content is present. So we can have Schedule section with that note.
But we also have Work Arrangement (Fully remote). That could be part of About the role or Benefits? Actually remote work is a work arrangement, could be part of About the role or Benefits. Since we have Benefits section already covering flexible work solutions including remote options, hybrid work schedules. So we could incorporate remote work there. But we need to avoid duplication. The posting says "Fully remote; must be willing to work rotational weekend and holidays." and later under Benefits: "Flexible work solutions including remote options, hybrid work schedules". There's some overlap. We should preserve all info, not duplicate? The instruction: Preserve ALL substantive information; do NOT invent or summarize away detail. It doesn't forbid duplication but we should avoid redundant repetition? It says do not summarize away detail; duplication is okay but maybe better to include each piece once. We can incorporate remote work in About the role or Benefits. Since Benefits already mentions flexible work solutions including remote options, hybrid work schedules, we can keep that there and note the fully remote requirement in About the role.
Schedule section: rotational weekend and holidays.
Now we need to output HTML fragment with headings
and content.
Structure:
About the role
Job summary paragraph(s) + Work arrangement sentence.
Responsibilities
- ... each responsibility
Requirements
Maybe combine Education And Experience and Licensure into Requirements. Could split into Education & Experience and Licensure sub-sections but we want few sections. Could keep as Requirements with two sub-lists? But we need to use - for any list. Could have nested lists? Probably fine to have separate
for each category under same heading. We'll do:
Requirements
Education and Experience:
...
Licensure:
...
But using inside is okay. Or we could just have two headings but that adds more sections. The instruction: prefer a few substantive sections over many thin ones. So we keep one Requirements heading with two lists.
Benefits
...
Schedule
Rotational weekend and holidays required.
Check we didn't miss any details: The job summary also mentions "Our Medical Directors, UM help develop and implement medical policies, procedures, and clinical guidelines aligned with contractual obligations and regulatory guidelines." etc. Already included.
We need to ensure we didn't omit any sentence from responsibilities list. Let's copy them exactly as in posting.
Responsibilities block from posting:
"Ensures quality and clinically sound services for all enrollees through associates and providers. Serves as medical advisor and manager for all clinically related activitiesEnsures that the organization’s medical policies and procedures adhere to contractual obligationsPerforms clinical case reviews in conjunction with the Medical Excellence Department. Demonstrates knowledge of prescribed and established medical procedures and practicesMaintains 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 obligationsManages 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. Work closely with a multidisciplinary team to ensure behavioral health management and quality management programs meet contractual obligationsWorks with
- for any list of duties/requirements/benefits. Use
for prose. We need to ensure we include all specifics: job summary paragraphs, work arrangement, responsibilities bullet list, education/experience bullet list, licensure bullet list, benefits list, schedule note. We must not create sections with filler. Avoid Pay. Let's extract details precisely. Job Summary paragraph: "In this role, you will lead the operational areas of the Utilization Management (UM) program including prospective, concurrent, and retrospective reviews. As a Medical Director, UM you ensure all patient care decisions and referrals are medically appropriate by using national and local criteria. Our Medical Directors, UM help develop and implement medical policies, procedures, and clinical guidelines aligned with contractual obligations and regulatory guidelines. They partner with Quality Improvement teams to analyze utilization trends and develop interventions to improve clinical effectiveness. Medical Directors, UM also serve as a key point of contact for physicians and providers, conducting peer-to-peer discussions to facilitate collaborative care and resolve issues. In addition, you will collaborate with Corporate Medical Directors, our Utilization and Case Management RNs and staff, and the Vice President, Medical Affairs." Work Arrangement: "Fully remote; must be willing to work rotational weekend and holidays." Responsibilities list (looks like a paragraph with many sentences separated by line breaks? We'll treat each sentence as a bullet item). Let's list: - Ensures quality and clinically sound services for all enrollees through associates and providers. - 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. - Work closely with a multidisciplinary team to ensure behavioral health management and quality management programs meet contractual obligations - Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff - Trains staff on medical issues and provides consultation to staff as appropriate - Assists 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 Education And Experience: - 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 Licensure: - Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) that is active and in good standing. - Must be able to obtain Pennsylvania license within 120 days of hire. - Additional medical licensure is required in all states where AmeriHealth Caritas has a line of business. - The application is expected to be initiated within 30 days of hire. - Candidates must be board certified in their specialty. - Must be clear of any sanctions by the applicable state or the Office of the Inspector General. - Must not be prohibited from participating in any Federally or state-funded healthcare programs. Benefits: - Flexible work solutions including remote options, hybrid work schedules, - Competitive pay, - Paid time off including holidays and volunteer events, - Health insurance coverage for you and your dependents on Day 1, - 401(k) - Tuition reimbursement and more. - For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. - A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. - Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement. Schedule note: "must be willing to work rotational weekend and holidays." Already in Work Arrangement. Could be separate Schedule section: "Rotational weekend and holidays required." But we already have Work Arrangement as prose maybe under About the role. However we need to include Schedule section if we want. The rule: include a section ONLY when posting has real specific content. The schedule content is present. So we can have Schedule section with that note. But we also have Work Arrangement (Fully remote). That could be part of About the role or Benefits? Actually remote work is a work arrangement, could be part of About the role or Benefits. Since we have Benefits section already covering flexible work solutions including remote options, hybrid work schedules. So we could incorporate remote work there. But we need to avoid duplication. The posting says "Fully remote; must be willing to work rotational weekend and holidays." and later under Benefits: "Flexible work solutions including remote options, hybrid work schedules". There's some overlap. We should preserve all info, not duplicate? The instruction: Preserve ALL substantive information; do NOT invent or summarize away detail. It doesn't forbid duplication but we should avoid redundant repetition? It says do not summarize away detail; duplication is okay but maybe better to include each piece once. We can incorporate remote work in About the role or Benefits. Since Benefits already mentions flexible work solutions including remote options, hybrid work schedules, we can keep that there and note the fully remote requirement in About the role. Schedule section: rotational weekend and holidays. Now we need to output HTML fragment with headings
and content. Structure:
About the role
Job summary paragraph(s) + Work arrangement sentence.
Responsibilities
- ... each responsibility
Requirements
Maybe combine Education And Experience and Licensure into Requirements. Could split into Education & Experience and Licensure sub-sections but we want few sections. Could keep as Requirements with two sub-lists? But we need to use- for any list. Could have nested lists? Probably fine to have separate
- for each category under same heading. We'll do:
Requirements
Education and Experience:
- ...
Licensure:
- ...
is okay. Or we could just have two headings but that adds more sections. The instruction: prefer a few substantive sections over many thin ones. So we keep one Requirements heading with two lists.
Benefits
- ...
Schedule
Rotational weekend and holidays required.
Check we didn't miss any details: The job summary also mentions "Our Medical Directors, UM help develop and implement medical policies, procedures, and clinical guidelines aligned with contractual obligations and regulatory guidelines." etc. Already included. We need to ensure we didn't omit any sentence from responsibilities list. Let's copy them exactly as in posting. Responsibilities block from posting: "Ensures quality and clinically sound services for all enrollees through associates and providers. Serves as medical advisor and manager for all clinically related activitiesEnsures that the organization’s medical policies and procedures adhere to contractual obligationsPerforms clinical case reviews in conjunction with the Medical Excellence Department. Demonstrates knowledge of prescribed and established medical procedures and practicesMaintains 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 obligationsManages 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. Work closely with a multidisciplinary team to ensure behavioral health management and quality management programs meet contractual obligationsWorks with