Medical Director II, Utilization Management

Devoted Health•Waltham, MA

1d•Remote

About The Position

A bit about this role: This position interacts with utilization management, clinical management, pharmacy, network management, data analytics, legal, finance as well as other health plan departments. As a Medical Director in Utilization Management, you share responsibility for leadership in the appropriate use of medical services within established quality and evidenced based guidelines as well as executing the essential functions below: Your Responsibilities and Impact will include: Assists in development and maintenance of an efficient UM program to meet the needs of health plan members commensurate with company values. Perform clinical reviews (i.e., part A, B, appeals, quality of care) and conduct peer to peer discussions. Participate in inter-rater reliability activities. Participate in analysis of utilization data and suggest improvement opportunities. Provide appropriate mentoring and leadership to clinical teams as well as develop relationships to support growth and fiscal responsibility. Participate in committees and workgroups to achieve department and corporate objectives. Provide clinical support and participate in utilization management, quality management, clinical services and care management programs to identify opportunities for improvement and efficiency. Serves as a clinical resource and subject matter expert to both clinical and non-clinical staff throughout the Devoted Health Plan. Active participation in acute and post acute clinical rounds. Conduct discussions with physicians in the Devoted network regarding: medical policies, utilization management, use of resources, and quality.

Requirements

Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required.
Five or more years of clinical practice experience.
Three (3) years of previous medical director experience working for a health plan, medical group, or hospital in utilization management or medical management.

Nice To Haves

Passionate about their work, eager to have fun with our team, motivated to be a part of a fast growing organization.
Excited by the process of developing and implementing new processes.
Belief that population health and a focus on smart allocation of scarce resources can lead to high value care both in terms of quality and safety.
Ability to remain calm in the midst of the storm, guiding others to smart, effective solutions
Comfort with ambiguity and a love for problem solving.

Responsibilities

Assists in development and maintenance of an efficient UM program to meet the needs of health plan members commensurate with company values.
Perform clinical reviews (i.e., part A, B, appeals, quality of care) and conduct peer to peer discussions.
Participate in inter-rater reliability activities.
Participate in analysis of utilization data and suggest improvement opportunities.
Provide appropriate mentoring and leadership to clinical teams as well as develop relationships to support growth and fiscal responsibility.
Participate in committees and workgroups to achieve department and corporate objectives.
Provide clinical support and participate in utilization management, quality management, clinical services and care management programs to identify opportunities for improvement and efficiency.
Serves as a clinical resource and subject matter expert to both clinical and non-clinical staff throughout the Devoted Health Plan.
Active participation in acute and post acute clinical rounds.
Conduct discussions with physicians in the Devoted network regarding: medical policies, utilization management, use of resources, and quality.