Medical Director - Utilization Management/Care Management, Select Health

Key Responsibilities

• Develop and implement UM and CM strategies using data analytics, technology, and cost-benefit analysis to optimize covered services and care management efforts.
• Participate in the creation, revision and enforcement of UM/CM policies, procedures, and protocols to meet regulatory and other accreditation requirements.
• From a clinical perspective, manage provider reviewers, concurrent reviews, prior authorizations, medical claims reviews, appeals, and grievances and ensure timely and accurate service authorizations consistent with regulatory and accreditation standards.
• Identify process improvements, redesign workflows, and implement processes including auto-approvals, alternative site criteria evaluation, artificial intelligence solutions and prior authorization efficiency where appropriate to reduce administrative burden.
• Participate in system innovation opportunities such as risk-based contracting, appropriate reduction of prior authorization or other identified opportunities to affect administrative simplification and reduce abrasion for members and providers.
• Monitor utilization trends, measure productivity metrics, and report on cost savings and quality outcomes across areas of responsibility.
• Build and maintain strong relationships with Select Health required vendors and clinical teams necessary to improve care quality and efficiency.
• Ensure adherence to state/federal regulations, accreditation standards, and contractual obligations; conduct provider education and training as necessary to facilitate compliance and adherence to quality measures.
• Supervise and mentor UM/CM staff, provide executive-level guidance, and support workforce planning as needed.
• Lead initiatives to improve member/provider experience, reduce unnecessary services, and enhance clinical decision support.

Skills

• Leadership
• Communication
• Taking Initiative
• Performance management
• Process Improvements
• Teamwork
• Workflow optimization
• Process documentation
• Health plan operation
• Computer Literacy

Qualifications

• Medical Doctor or Doctor of Osteopathic Medicine degree with Board Certification in one of the following areas: Internal Medicine, Pediatrics, Family Practice, Psychiatry or Emergency Medicine.
• Requires current MD or DO licensure within the State of Utah, Idaho, Nevada or Colorado.
• Five years of experience in clinical practice.

Additional Details

FTE: 1.0
Salary: $332,300 - 377,400 based on relevant experience.
Eligible for an annual leadership incentive opportunity based on system goals.
In addition to the annual salary, to show our commitment to you and assist with your transition, we may offer a sign-on and relocation bonus when applicable.
Minimum Qualifications: Medical Doctor or Doctor of Osteopathic Medicine degree with Board Certification in one of the following areas: Internal Medicine, Pediatrics, Family Practice, Psychiatry or Emergency Medicine. Requires current MD or DO licensure within the State of Utah, Idaho, Nevada or Colorado. Five years of experience in clinical practice.
Preferred Qualifications: Utilization management, care management and/or experience in policy related work for a health plan or managed care organization. Previous management experience. Experience with financial and medical expense management. Understanding of health care delivery system as it relates to government programs and agencies. Excellent communication skills including ability to establish and maintain rapport with coworkers, providers, brokers, employers, plan members, representatives/executives from other health care entities, government and regulatory bodies and others in the community.