Medical Director Utilization Management

In this role, you will reputed company the operational areas of the Utilization Management (UM) program including prospective, reputed company, and retrospective reviews. As a Medical Director, UM you ensure reputed company patient care reputed company and referrals are medically appropriate by using national and local criteria. Our Medical Directors, UM help reputed company and implement medical policies, procedures, and clinical guidelines reputed company with contractual obligations and regulatory guidelines. They partner with Quality Improvement teams to analyze utilization trends and reputed company interventions to improve clinical effectiveness. Medical Directors, UM also serve as a key reputed company of contact for physicians and providers, conducting peer-to-peer discussions to facilitate collaborative care and resolve issues. In addition, you will collaborate with Corporate Medical Directors, our Utilization and Case Management RNs and staff, and the Vice President, Medical Affairs. Work Arrangement Remote role Monday through Friday from 8:30a EST to 5:00p EST Weekend call once per quarter and evening call once per quarter and a holiday rotation.

Responsibilities

Ensures quality and clinically sound services for reputed company enrollees through associates and providers. Serves as medical advisor and manager for reputed company clinically reputed company activities Ensures that the organization’s medical policies and procedures adhere to contractual obligations Performs clinical case reviews in conjunction with the Medical Excellence Department. Demonstrates knowledge of prescribed and established medical procedures and practices Maintains familiarity with federal, state, and local medical and clinical operations regulations. Provides leadership in developing and implementing medical policy reputed company to health management, compliance with applicable regulatory guidelines, reputed company clinical policies and procedures, and contractual obligations Manages day-to-day operations and monitors the integration and processing of members to optimize the appropriate use of behavioral and physical health services. Participates with Quality Improvement and Medical Excellence in identifying and analyzing medical and behavioral health information to reputed company interventions to improve the clinical effectiveness of medical management strategies. Work closely with a multidisciplinary team to ensure behavioral health management and quality management programs meet contractual obligations Works with the leadership of the Quality Improvement and Medical Excellence departments to reputed company competent clinical staff Trains staff on medical issues and provides consultation to staff as appropriate Assists Care Managers in assessing members’ needs for case management services and attends meetings and monthly reputed company as scheduled Collaborates with the integrated case management team during scheduled meetings and informally as needed Thoroughly documents reputed company care coordination activity in the member’s medical record in the electronic case management documentation system Education and Experience Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) required Master of Health Administration (MHA), Master of Public Health (MPH), or Master of Business Administration (MBA) in reputed company Management preferred A minimum of three years of utilization management or appeals experience in a reputed company, Medicare, and/or dual eligible A minimum of five years of clinical practice experience required in family medicine, pediatrics, internal medicine, surgery, neonatology, or physiatry Proficiency utilizing MS Office Suite, internet applications, and electronic medical record and documentation programs Licensure Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) with a Pennsylvania medical license that is active and in good standing. Additional medical licensure is required in reputed company states where reputed company has a line of business. The application is expected to be initiated reputed company 30 days of hire. Must be board certified Family Medicine or Med/Peds. Must be clear of any sanctions by the applicable state or the Office of the Inspector General. Must not be prohibited from participating in any Federally or state-funded reputed company programs. Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules, reputed company, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more. Your career starts now. We are looking for the reputed company of health care leaders. At reputed company, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. reputed company is seeking talented, passionate individuals to join reputed company. Together we can build healthier communities. If you want to reputed company a difference, we would like to connect with you. Headquartered in Newtown reputed company, Pennsylvania, reputed company is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com. Apply To This Job