Medical Director, Utilization Management (Remote)

About the role

The Medical Director, Utilization Management is responsible for assuring physician commitment and delivery of comprehensive high-quality health care to UPMC Health Plan members. This fully remote role oversees adherence to quality and utilization standards through committee delegations and establishes an effective working relationship between UPMC Health Plan's Network and its physicians, hospitals, and other providers.

Responsibilities

• Provide leadership direction for provider credentialing processes.
• Ensure physicians devote sufficient time to the CHC-MCO to provide timely medical decisions, including after-hours consultation as needed.
• Provide leadership and direction in meeting Quality Improvement and Care Management goals directed at improvements in member health status outcomes and established business strategies.
• Provide expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan.
• Participate in daily utilization management and quality improvement review processes, including concurrent, prospective, and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns.
• Stay current with accepted standards and professional developments in quality improvement and utilization management.
• Communicate and educate network providers regarding clinical guidelines, pathways, protocols, and standards related to quality and utilization processes.
• Report and communicate reportable communicable diseases in accordance with statute.
• Interact with physicians regarding opportunities to improve member satisfaction and compliance with Utilization Management and Quality Improvement policies and procedures.
• Work with the DOH State and District Office Epidemiologists in partnership with the designated county/municipal health department staff to appropriately report reportable conditions in accordance with 28 Pa. Code 27.1 et seq.
• Support implementation of the Health Plan's Quality Improvement and Care Management Programs through daily interventions.
• Represent the Health Plan in external accreditation and certification activities.
• Act as first-level physician reviewer for all cases referred by the Quality Improvement and Care Management Departments.
• Support adherence to quality and utilization standards and establish effective working relationships between UPMC Health Plan's Network and its physicians, hospitals, and other providers.

Requirements

• Doctor of Medicine or Doctor of Osteopathy from an accredited school.
• Minimum of 5–10 years of clinical experience.
• Managed care experience preferred.
• Experience with payer utilization management highly preferred.
• Preference given to candidates with board certification in Internal Medicine, Family Medicine, Geriatric Medicine, or Emergency Medicine.
• PA Medical License.