Senior Medical Director Utilization Management

About the Role

This position oversees the quality of clinical care for enrollees with medical conditions and their providers, ensuring a high-performing Medical Management system that adheres to contractual and regulatory requirements. The role utilizes evidence-based standards for coverage determinations and requires a remote work arrangement with on-call rotational evening and weekend shifts.

Responsibilities

• Ensures the provision of quality and clinically sound services to all enrollees by associates and providers.
• Leads a team of Medical Directors responsible for utilization management, prior authorization, behavioral health reviews, and appeals.
• Demonstrates knowledge of prescribed and established medical procedures and practices.
• Maintains familiarity with federal, state, and local regulations pertaining to medical and clinical operations.
• Provides leadership in the development and implementation of medical policy related to health management.
• Maintains compliance with applicable regulatory guidelines, clinical policies, and contractual obligations.
• Manages day-to-day operations and monitors the integration and processing of members to optimize appropriate use of behavioral and physical health services.
• Participates in the identification and analysis of medical and behavioral health information to develop interventions for improving clinical effectiveness.
• Works closely with a multidisciplinary team to ensure behavioral health and quality management programs meet contractual obligations.
• Develops competent clinical staff in collaboration with Quality Improvement and Medical Excellence departments.
• Trains staff on medical issues and provides consultation as appropriate.
• Assists in assessing members’ need for case management services.
• Attends case management 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 medical record using the electronic case management system.
• Adheres to AmeriHealth Family of Companies policies, procedures, mission, and values.
• Leads at least 2 High Value Opportunities (cost management) initiatives per year.
• Leads training and retraining efforts for critical decision-making in utilization management, appeals, and pharmacy management.
• Leads continuous quality improvement for the clinical team, including ongoing audits of utilization management, peer-to-peer reviews, and appeals.
• Acts as a subject matter expert for the medical director and pharmacy teams.
• Contributes to the operations of the medical director team, including scheduling.

Requirements

• MD licensed to practice in the state as a medical director; must be willing to obtain additional state licenses.
• Board-certified in their medical specialty.
• Must be clear of any sanctions by the applicable state or Office of the Inspector General.
• Must not be prohibited from participating in any Federally or State-funded healthcare programs.

Experience

• A minimum of 3 to 5 years of State Management Organization (SMO) experience preferred.
• A minimum of 5 years in or a combination of the following:
  • Full-time experience as an administrator in a Medicare or state-level Medicaid program, HMO, PPO, large Health Care Organization, or health plan.
  • Clinical practice experience.
• Experience with auditing and quality initiatives preferred.
• Information Technology experience.

Skills

• Strong written and oral communication skills.
• Demonstrated competency in the use of healthcare data.
• Excellent interpersonal communication and presentation skills.
• Experienced in conflict resolution and negotiation.
• Understanding of and expertise in quality improvement and medical economics.
• Strong leadership skills.
• Excellent analytical and problem-solving skills.
• Demonstrated ability to assess department work quality and implement process improvements for regulatory compliance.
• Maintains current knowledge of and applies all applicable licensing, regulatory, and industry standards.

Benefits

• Flexible work solutions including remote options and hybrid work schedules.
• Competitive pay.
• Paid time off including holidays and volunteer events.
• Health insurance coverage for you and your dependents starting on Day 1.
• 401(k) retirement plan.
• Tuition reimbursement.

For roles that are 100% remote or hybrid, a reliable high-speed internet connection is required (minimum 50 Mbps download and 5 Mbps upload). Those fully remote associates residing in states where service is required by contract, law, or regulation will be eligible for reimbursement.