Medical Director, Utilization Management- Remote

Remote Medical Director

The Remote Medical Director works with Senior Medical Officers, Regional Medical Officers, Extensivists, the Healthcare Services Team (Case managers, Social Workers, Utilization Managers) to develop and implement methods to optimize use of Institutional and Outpatient services for all patients while also ensuring the quality of care provided.

• Processes second level reviews in compliance with Medicare/CMS: NCD, LCD and Milliman guidelines for Inpatient, Outpatient, Skilled Facilities Level of Care and Pharmacy.
• Provides appropriate level of care classifications as well as continued stay reviews in compliance with CMS and Milliman guidelines.
• Acts as a liaison between the medical staff, utilization review and 3rd party payers to effectively promote the appropriate levels of medical care.
• Reviews the entire claim denial process, including Appeals and Grievances.
• Serves as a Physician member of the utilization review team.
• Works with Interdisciplinary Team to develop case management protocols and provide oversight for NP’s/PA’s training.
• Serves as a Clinical Leader for HEDIS and STARS projects and serves as Clinical Advisor for HCC and RAF.
• Serves as a Chairperson for Medical Quality Committee and provide Clinical Oversight for Chronic Disease Management programs and Quality Outcome.
• Collaborates closely and provide assistance to Quality Director.
• Works with Extensivists and Middle Level Practitioners (NP’s/PA’s) to reduce length of institutional stay, all cause readmission reduction and ER overutilization ensuring patients and therapeutic modalities.
• Affords the organization to challenge physician practices in order to achieve the organization's clinical outcomes and quality goals.
• Oversees assigned staff. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.

Experience

• Minimum of 3 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.
• Experience as a Physician Advisor a plus.

Education

• Completion of medical school and specialty residency (preferably in internal medicine) required.
• Subspecialty or other post-residency fellowship and board certification preferred.

Specialized Skills

• Ability to communicate positively, professionally and effectively with others;
• Provide leadership, teach and collaborate with others.
• 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.
• Effective written and oral communication skills;
• Ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly.
• Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.

Work Environment

• While performing the duties of this job, the employee is regularly required to talk or hear.
• The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
• The employee frequently lifts and/or moves up to 10 pounds.

Specific Vision Abilities

• Close vision and the ability to adjust focus.

Pay Range

$198,219.00 - $297,329.00

Disclaimer

Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com.