Per Diem Medical Director UM

Amerihealth Caritas•,

9d•Remote

About The Position

The Per Diem UM Medical Director will be responsible for performing daily medical reviews, appeals, participating in appeal panels, and handling correspondence regarding review determinations and physician peer review activities. This role involves identifying and implementing evidence-based practice guidelines, overseeing the quality of clinical care for network and non-network providers, and utilizing evidence-based standards for coverage determinations. The position also requires adherence to management policies and health plan inter-rater reliability guidelines. The Per Diem UM Medical Director will serve as a medical advisor, manage clinically related activities, and ensure that medical policies and procedures align with contractual obligations. They will perform clinical case reviews, demonstrate knowledge of medical procedures and practices, and maintain familiarity with relevant federal, state, and local regulations. Compliance with regulatory guidelines, clinical policies, and contractual obligations is essential. The role involves managing day-to-day operations, monitoring member integration and processing to optimize service utilization, and collaborating with Quality Improvement and Medical Excellence departments to analyze medical and behavioral health information and develop interventions. This position works closely with a multidisciplinary team to ensure behavioral health management and quality management programs meet contractual obligations, and assists in developing competent clinical staff. The Medical Director will attend case management meetings and rounds, collaborate with the integrated case management team, and thoroughly document all care coordination activities in the electronic case management system. Adherence to AmeriHealth Caritas Family of Companies (ACFC) policies, procedures, mission, and values is expected, along with performing other assigned duties.

Requirements

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 a specialty with a current and unrestricted license.
Must be clear of any sanctions by the applicable state or Office of the Inspector General.
Must not be prohibited from participating in any Federally or State funded healthcare programs.
1 to 3 years of Health Plan experience.
Strong written and oral communication skills-required.
Demonstrated competency in use of healthcare data.
Demonstrated excellent interpersonal communication skills and presentation skills.
Experienced in conflict resolution and negotiation.
Understanding of and expertise in quality improvement and medical economics.
Strong leadership skills.
Excellent analytical and problem-solving skills.
Demonstrated ability to access department’s work quality and develop / implement process improvements to achieve regulatory and oversight compliance.
Maintain current knowledge of and applies all applicable licensing, regulatory and industry standards.
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.

Responsibilities

Performing daily medical reviews, appeals, participating in appeal panel as appropriate, correspondence regarding review determinations and physician peer review activities.
Identifying and implementing evidence-based practice guidelines throughout the provider network.
Overseeing the quality of clinical care for network and non-network providers.
Utilizing evidence-based standards in making coverage determinations.
Ensuring the provision of quality and clinically sound services to all Enrollees by associates and Providers.
Serving as medical advisor and manager for all clinically related activities.
Assuring that organization medical policies and procedures adhere to contractual obligations.
Performing clinical case reviews in conjunction with Medical Excellence Department.
Demonstrating knowledge of prescribed and established medical procedures and practices.
Maintaining familiarity with federal, state and local regulations that may pertain to the medical and clinical operations.
Maintaining compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations.
Managing day-to-day operations and monitoring the integration and processing of members to optimize appropriate use of behavioral and physical health services.
Participating with Quality Improvement and Medical Excellence in the identification and analysis of medical and behavioral health information to develop interventions to improve clinical effectiveness of medical management strategies.
Working closely with a multidisciplinary team to ensure behavioral health management and quality management programs are meeting contractual obligations.
Working with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff.
Attending case management meetings and monthly rounds as scheduled.
Collaborating with the integrated case management team, during scheduled meetings and informally as needed.
Thoroughly documenting all care coordination activity in the member medical record in the electronic case management documentation system.
Adhering to AmeriHealth Family of Companies (ACFC) policies and procedures and supporting and carrying out the ACFC mission and values.
Other duties as assigned.