Medical Director Utilization Management

About the role

AmeriHealth Caritas is seeking talented, passionate individuals to join our team. We are looking for the next generation of health care leaders to lead the operational areas of the Utilization Management (UM) program.

Responsibilities

• 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.
• Works 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.

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) 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.

Skills

• Knowledge of medical procedures and practices.
• Familiarity with federal, state, and local medical and clinical operations regulations.
• Ability to manage day-to-day operations and monitor member integration.
• Experience with clinical case reviews and medical policy development.
• Strong communication and collaboration skills.

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.
• Tuition reimbursement.

Pay

Commensurate with experience.

Schedule

Full-time, remote position with rotational weekend and holiday work.