Medical Director - Utilization Management/Care Management, Select Health
About The Position
Select Health, a regional health plan serving over a million members across Utah, Idaho, Nevada, and Colorado, is seeking an experienced Medical Director with expertise in Utilization Management (UM), Care Management (CM), Health Plan accreditation, and other operational and regulatory functions. This role reports directly to the Chief Medical Officer and leads the UM and CM functions from a clinical perspective. The Medical Director ensures that care services are high quality, appropriate, efficient, and compliant with regulatory and accreditation standards. The position combines oversight of UM and CM functions with Select Health strategies to ensure members receive coverage and services for high-quality, appropriate, efficient, and cost-effective care.
Requirements
- Medical Doctor or Doctor of Osteopathic Medicine degree with Board Certification in Internal Medicine, Pediatrics, Family Practice, Psychiatry, or Emergency Medicine.
- Current MD or DO licensure within the State of Utah, Idaho, Nevada, or Colorado.
- Five years of experience in clinical practice.
- Leadership skills.
- Communication skills.
- Taking Initiative.
- Performance management.
- Process Improvements.
- Teamwork.
- Workflow optimization.
- Process documentation.
- Health plan operation knowledge.
- Knowledge of Federal, state, and local regulations.
- Computer Literacy.
Nice To Haves
- Utilization management, care management, and/or experience in policy-related work for a health plan or managed care organization.
- Previous management experience.
- Experience with financial and medical expense management.
- Understanding of the healthcare delivery system as it relates to government programs and agencies.
- Excellent communication skills, including the ability to establish and maintain rapport with coworkers, providers, brokers, employers, plan members, representatives/executives from other healthcare entities, government and regulatory bodies, and others in the community.
Responsibilities
- Develop and implement UM and CM strategies using data analytics, technology, and cost-benefit analysis to optimize covered services and care management efforts.
- Participate in the creation, revision, and enforcement of UM/CM policies, procedures, and protocols to meet regulatory and other accreditation requirements.
- From a clinical perspective, manage provider reviewers, concurrent reviews, prior authorizations, medical claims reviews, appeals, and grievances, ensuring timely and accurate service authorizations consistent with regulatory and accreditation standards.
- Identify process improvements, redesign workflows, and implement processes including auto-approvals, alternative site criteria evaluation, artificial intelligence solutions, and prior authorization efficiency where appropriate to reduce administrative burden.
- Participate in system innovation opportunities such as risk-based contracting, appropriate reduction of prior authorization, or other identified opportunities to affect administrative simplification and reduce abrasion for members and providers.
- Monitor utilization trends, measure productivity metrics, and report on cost savings and quality outcomes across areas of responsibility.
- Build and maintain strong relationships with Select Health required vendors and clinical teams necessary to improve care quality and efficiency.
- Ensure adherence to state/federal regulations, accreditation standards, and contractual obligations; conduct provider education and training as necessary to facilitate compliance and adherence to quality measures.
- Supervise and mentor UM/CM staff, provide executive-level guidance, and support workforce planning as needed.
- Lead initiatives to improve member/provider experience, reduce unnecessary services, and enhance clinical decision support.
Benefits
- Annual leadership incentive opportunity based on system goals.
- Sign-on bonus (when applicable).
- Relocation bonus (when applicable).
- Comprehensive benefits package covering a wide range of programs to foster a sustainable culture of wellness (living healthy, happy, secure, connected, and engaged).
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What This Job Offers
Job Type
Full-time
Career Level
Executive
Education Level
Ph.D. or professional degree
