Medical Director Utilization Management

Amerihealth Caritas•,

2d•Remote

About The Position

The Medical Director, Utilization Management, provides organizational leadership in the operational areas of appeals, utilization review, quality improvement, and related policy and practice initiatives in collaboration with the Corporate Medical Director(s), Utilization Management, and the Vice President, Medical Affairs. The following responsibilities are regarding enrollees with medical conditions and their providers: Identifying and implementing evidence-based practice guidelines throughout the provider network. Overseeing the quality of clinical care for network and non-network providers. Engaging the provider network in Continuous Quality Improvement through the diffusion of practice standards and an internal quality assurance program that measures network provider performance against high-quality standards, especially the HEDIS program’s performance standards. Ensuring a high-performing Medical Management system that adheres to the terms of contracts and all relevant regulatory requirements. Utilizing evidence-based standards in making coverage determinations.

Requirements

A minimum of five (5 )years of clinical practice experience is required.
Doctor of Medicine (MD) or Doctor of Osteopathic Medicine licensed to practice as a medical director; additional state licensure required in all states where ACFC has a line of business, and that application is expected within 120 days of hire.
Must be Board-certified in Family Medicine, Internal Medicine, Pediatrics, or Emergency Medicine.
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 healthcare programs.
Strong written and oral communication skills are required.

Nice To Haves

MHA, MPH, or MBA in healthcare management preferred.
A minimum of three (3) years of utilization management or appeal experience in a Medicaid, Medicare, dual eligible, or commercial health plan is preferred.
Experience working with Medicaid or Medicare preferred.
Proficiency utilizing MS Office (Word, Excel, Outlook), internet applications, and electronic medical record and documentation programs.
Preferred Pennsylvania license, must be willing to obtain Pennsylvania and additional licenses where AmeriHealth Caritas has health plans.

Responsibilities

Provides organizational leadership in the operational areas of appeals, utilization review, quality improvement, and related policy and practice initiatives in collaboration with the Corporate Medical Director(s), Utilization Management, and the Vice President, Medical Affairs.
Identifies and implements evidence-based practice guidelines throughout the provider network.
Oversees the quality of clinical care for network and non-network providers.
Engages the provider network in Continuous Quality Improvement through the diffusion of practice standards and an internal quality assurance program that measures network provider performance against high-quality standards, especially the HEDIS program’s performance standards.
Ensures a high-performing Medical Management system that adheres to the terms of contracts and all relevant regulatory requirements.
Utilizes evidence-based standards in making coverage determinations.
Ensures quality and clinically sound services for all enrollees through associates and providers.
Serves as medical advisor and manager for all clinically related 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 related to health management, compliance with applicable regulatory guidelines, AmeriHealth Caritas 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 develop interventions to improve the clinical effectiveness of medical management strategies.
Works 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 develop 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 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’s medical record in the electronic case management documentation system.