Medical Director, Utilization Management-Remote

General Duties/Responsibilities

• Second level reviews in compliance with Medicare/CMS: NCD, LCD and Milliman guidelines for Inpatient, Outpatient, Skilled Facilities Level of Care and Pharmacy.
• Provide appropriate level of care classifications as well as continued stay reviews in compliance with CMS and Milliman guidelines.
• Act as a liaison between the medical staff, utilization review and third-party payers to effectively promote the appropriate levels of medical care.
• Review the entire claim denial process, including pending claims, Appeals and Grievances.
• Serve as a Physician member of the utilization review team.
• Ensure appropriate service utilization by monitoring over- and underutilization.
• Work with Interdisciplinary Team to develop AHC Utilization Management protocols, including auto-approvals and market specific protocols.
• Develop training material and assisting UM Manager to conduct Physicians' annual Interrater reliability testing.
• Serve as a Subject Matter Expert (CME) to Regional Medical Officers and/or Extensivists during concurrent reviews.
• Serve as a Chairperson for Medical Quality Committee and provide Clinical Oversight of Quality Outcomes.
• Collaborate closely and assist Quality Director.
• Work with Provider Relation, Network Management and local Regional Medical Officers to ensure community Physician education on UM processes and regulations.
• Absorb and assist in challenging physician practices to achieve the organization's clinical outcomes.

Supervisory Responsibilities

• UM Clinical Staff Oversight

Minimum Requirements

• 3-5 years of experience in hospital-wide or skilled nursing facility position involving clinical care, quality management, utilization and case management, or medical staff governance required.
• Completion of medical school and specialty residency (preferably in internal medicine).
• Board Certification.
• Current, non-restricted licensure as required for clinical practice in the State or US territory in which medical decisions are being made.

Specialized Skills

• Ability to build rapport with medical staff and management leadership to obtain necessary approvals of new strategies for utilization management.
• Knowledge of current medical literature, research methodology, healthcare delivery systems, healthcare financial/reimbursement issues, and medical staff organizations.
• Dedication to the delivery of high-quality, cost-effective, efficient patient care services.
• Excellent communication skills.
• Great attention to detail as well as taking pride in being a good team member and communicating effectively with medical staff.

Essential Physical Functions

• Regularly required to talk or hear.
• Frequent lifting and/or moving up to 10 pounds.

Pay Range

$262,145.00 - $393,217.00