Sr Medical Dir UM

Amerihealth Caritas • ,

2d • Remote

About The Position

The Sr Medical Director, UM will oversee the quality of clinical care for network and non-network providers, ensuring a high-performing Medical Management system that adheres to contract terms and regulatory requirements. This role utilizes evidence-based standards for coverage determinations and leads a team of Medical Directors responsible for utilization management, prior authorization, behavioral health reviews, and appeals. The position requires a strong understanding of medical procedures, federal and state regulations, and the ability to develop and implement medical policy. The role also involves managing day-to-day operations, monitoring member integration, and collaborating with Quality Improvement and Medical Excellence departments to enhance clinical effectiveness and staff competency. The Sr Medical Director will also train staff, consult on medical issues, assess case management needs, and document care coordination activities. Adherence to AmeriHealth Caritas policies and values is essential, as is leading cost management initiatives and continuous quality improvement efforts for the clinical team. The role acts as a subject matter expert for medical director and pharmacy teams and contributes to the operational functions of the medical director team, including scheduling.

Requirements

• MD licensed to practice in the state as a medical director.
• Must be willing to obtain additional state licenses
• Must be Board-certified in their medical specialty.
• 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
• A minimum of 3 to 5 years State Management organization (SMO) experience preferred
• A minimum of 5 years in or a combination of the following: full-time experience as an administrator in a Medicare or state-level Medicaid program, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), large Health Care Organization, health plan, or any combination thereof
• Clinical practice experience.
• Experience with auditing and quality initiatives preferred
• Information Technology 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 apply all applicable licensing, regulatory, and industry standards.

Nice To Haves

• A minimum of 3 to 5 years State Management organization (SMO) experience preferred
• Experience with auditing and quality initiatives preferred

Responsibilities

• Overseeing the quality of clinical care for network and non-network providers
• Assuring 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.
• Ensures the provision of quality and clinically sound services to all Enrollees by associates and Providers
• Leads a team of Medical Directors responsible for utilization management, prior authorization, behavioral health reviews, and appeals
• Demonstrates knowledge of prescribed and established medical procedures and practices
• Maintains familiarity with federal, state, and local regulations that may pertain to the medical and clinical operations
• Provides leadership in the development and implementation of medical policy as it relates to health management
• Maintains 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 appropriate use of behavioral and physical health services
• Participates 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
• Works closely with a multidisciplinary team to ensure behavioral health management and quality management programs are meeting 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 IHCM Managers in assessing members’ need for case management services
• Attends case management 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 medical record in the electronic case management documentation system.
• Adheres to AmeriHealth Family of Companies (ACFC) policies and procedures and supports and carries out the ACFC mission and values
• Leads at least 2 High Value Opportunities (cost management) initiatives per year
• Leads all efforts to train/retrain current and new hires with regards to critical decision making for utilization management, appeals, and pharmacy management
• Leads all efforts in continuous quality improvement for clinical team, including ongoing audits of utilization management, peer-to-peer, quality of care reviews, appeals, and delegates oversight
• Acts as a subject matter expert in areas relevant to the medical director and pharmacy teams
• Contributes to the operations of the medical director team for functions such as scheduling

Benefits

• Flexible work solutions including remote options, hybrid work schedules
• Competitive pay
• Paid time off including holidays and volunteer events
• Health insurance coverage for you and your dependents on Day 1
• 401(k)
• Tuition reimbursement
• Access to a reliable high-speed internet connection to support daily job responsibilities (for remote/hybrid roles)
• Reimbursement for internet service (for fully remote associates in states where service is required by contract, law, or regulation)

What This Job Offers

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