Medical Director - Utilization Management/Care Management, Select Health
About The Position
Select Health, a regional health plan with over a million members serving all lines of business in Utah, Idaho, Nevada and Colorado, is seeking an experienced Medical Director with expertise in Utilization Management (UM), Care Management (CM) and Health Plan accreditation and other operational and regulatory functions. The Medical Director of Utilization Management/Care Management, reporting directly to the Chief Medical Officer, leads the UM and CM functions for Select Health from a clinical perspective, ensuring that care services are high quality, appropriate, efficient and in compliance with regulatory and accreditation standards. The role combines oversight of the 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 one of the following areas: 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.
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 health care delivery system as it relates to government programs and agencies.
- Excellent communication skills including ability to establish and maintain rapport with coworkers, providers, brokers, employers, plan members, representatives/executives from other health care 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 and ensure 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 such 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
- Eligible for an annual leadership incentive opportunity based on system goals
- Sign-on and relocation bonus when applicable
- Comprehensive benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
- 100+ learning options to choose from, including undergraduate studies, high school diplomas, and professional skills and certificates.
- PEAK program offers up-front tuition coverage paid directly to the academic institution.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Education Level
Ph.D. or professional degree
