Per Diem Medical Director Utilization Management

Amerihealth Caritas • ,

1d • Remote

About The Position

The Per Diem UM Medical Director reports to the Senior Medical Director of UM and performs medical reviews, appeals, appeal-panel participation as appropriate, determination correspondence, and physician peer reviews. The role identifies and implements evidence-based practice guidelines across the provider network, oversees the quality of clinical care delivered by network and non-network providers, uses evidence-based standards for coverage determinations, and follows medical management policies and inter-rater reliability guidelines.

The Medical Director helps ensure enrollees receive quality, clinically sound services; advises and manages clinically related activities; and ensures medical policies and procedures meet contractual obligations. The role conducts clinical case reviews with the Medical Excellence Department, maintains knowledge of medical procedures and applicable regulations, and supports compliance with regulatory guidance, company policies, and contractual requirements. It also monitors day-to-day integration and processing of members to support appropriate use of behavioral and physical health services.

Working with Quality Improvement, Medical Excellence, and multidisciplinary teams, the Medical Director analyzes clinical information, develops interventions to improve clinical effectiveness, supports the development of competent clinical staff, and helps ensure behavioral health and quality management programs meet contractual obligations. The role participates in scheduled case management meetings and rounds, collaborates with integrated case management, documents care coordination in the electronic case management system, and supports AmeriHealth Caritas policies, mission, and values.

This is a fully remote, per diem role requiring a minimum of 10 and no more than 20 hours per week. Evening, weekend, and holiday coverage is required. Remote associates need reliable high-speed internet with at least 50 Mbps download and 5 Mbps upload. Fully remote associates residing in states where reimbursement is required by contract, law, or regulation may submit for reimbursement.

Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• Board certification in a specialty.
• Current and unrestricted medical license.
• Additional state licensure is required in all states where ACFC has a line of business; the application is expected within 120 days of hire.
• Must be clear of sanctions by the applicable state or the Office of the Inspector General.
• Must not be prohibited from participating in federally or state-funded healthcare programs.
• At least 1 year of health plan experience.
• Strong written and oral communication skills.
• Demonstrated competency in using healthcare data.
• Excellent interpersonal communication and presentation skills.
• Experience in conflict resolution and negotiation.
• Understanding of and expertise in quality improvement and medical economics.
• Strong leadership skills.
• Excellent analytical and problem-solving skills.
• Ability to assess department work quality and develop and implement process improvements to achieve regulatory and oversight compliance.
• Ability to maintain current knowledge of and apply applicable licensing, regulatory, and industry standards.
• Reliable high-speed internet access with at least 50 Mbps download and 5 Mbps upload.

Responsibilities

• Perform daily medical reviews, appeals, appeal-panel participation as appropriate, correspondence regarding review determinations, and physician peer reviews.
• Identify and implement evidence-based practice guidelines throughout the provider network.
• Oversee the quality of clinical care provided by network and non-network providers.
• Use evidence-based standards when making coverage determinations and follow medical management policies and inter-rater reliability guidelines.
• Ensure enrollees receive quality, clinically sound services from associates and providers.
• Serve as medical advisor and manager for clinically related activities.
• Ensure organizational medical policies and procedures adhere to contractual obligations.
• Perform clinical case reviews in conjunction with the Medical Excellence Department.
• Maintain familiarity with federal, state, and local regulations relevant to medical and clinical operations.
• Maintain compliance with regulatory guidelines, company clinical policies and procedures, and contractual obligations.
• Manage day-to-day operations and monitor member integration and processing to optimize appropriate use of behavioral and physical health services.
• Work with Quality Improvement and Medical Excellence to identify and analyze medical and behavioral health information and develop interventions that improve clinical effectiveness.
• Collaborate with multidisciplinary teams to ensure behavioral health management and quality management programs meet contractual obligations.
• Work with Quality Improvement and Medical Excellence leadership to develop competent clinical staff.
• Attend case management meetings and monthly rounds as scheduled.
• Collaborate with the integrated case management team during scheduled meetings and informally as needed.
• Thoroughly document care coordination activity in members' medical records using the electronic case management documentation system.
• Adhere to AmeriHealth Family of Companies policies and procedures and support its mission and values.

Benefits

• Flexible work solutions, including remote options and hybrid work schedules.
• Competitive pay.
• Paid time off, including holidays and volunteer events.
• Health insurance coverage for associates and their dependents beginning on Day 1.
• 401(k).
• Tuition reimbursement.

What This Job Offers

• Job Type: Part-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree