Medical Director Utilization Management

Amerihealth Caritas•,

3d•Remote

About The Position

In this role, you will lead the operational areas of the Utilization Management (UM) program including prospective, concurrent, and retrospective reviews. As a Medical Director, UM you ensure all patient care decisions and referrals are medically appropriate by using national and local criteria. Our Medical Directors, UM help develop and implement medical policies, procedures, and clinical guidelines aligned with contractual obligations and regulatory guidelines. They partner with Quality Improvement teams to analyze utilization trends and develop interventions to improve clinical effectiveness. Medical Directors, UM also serve as a key point 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.

Requirements

Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) required
A minimum of three years of utilization management or appeals experience in a Medicaid, 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
Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) that is active and in good standing.
Must be able to obtain Pennsylvania license within 120 days of hire.
Additional medical licensure is required in all states where AmeriHealth Caritas has a line of business. The application is expected to be initiated within 30 days of hire.
Candidates must be board certified in their specialty.
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.
For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Nice To Haves

Master of Health Administration (MHA), Master of Public Health (MPH), or Master of Business Administration (MBA) in Healthcare Management preferred

Responsibilities

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. 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 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