Reporting to the Vice President of Medical Policy and Utilization Review, the Utilization Review Medical Director will be responsible for providing leadership and subject matter expertise to our utilization management group. This role is a key role in helping our organization provide high quality, equitable care to our rapidly growing membership. The incumbent will have significant experience with utilization review, ideally experience with public programming, and excellent clinical judgment. They will work well both independently and in conjunction with a diverse team, improving operations and efficiency, using excellent communication skills to interact with professionals internally and externally.
Primary responsibility for performing daily medical reviews, appeals as appropriate, correspondence regarding review determinations and physician peer review activities.
Discuss specific clinical issues with attending physicians and CCA clinicians
Document case review findings, actions, and outcomes in accordance with Utilization Management policies; meets health plan inter-rater reliability guidelines
Appropriately access clinical specialty panel physicians to assist in complex or difficult case
Ensure compliance with medical policy. Maintains compliance with all federal, state and local regulatory guidelines.
Serve as the lead for CCAs Utilization Review functions working closely with other medical management team members.
Support the development of utilization management policy initiatives.
Support the development and implementation of medical policy, including recommendations for modifications to enhance efficiency and effectiveness.
Partner with the VPUM to direct the efforts of the utilization review and pre-certification functions to accomplish objectives within policy and budget.
Serve as a clinical resource and coach for the utilization management team
Is available and accessible to the utilization management team throughout the day to respond to clinical issues
Monitor utilization reports, identifying changes in utilization or access patterns and monitor overall trends on a weekly basis
Provide education to internal care management and clinician staff
Provide clinical input to specific projects as required by the organization or vendors
Maintain working knowledge of current quality improvement issues and tools
Contribute to development of Medical Expense Action plans to implement tactics to address areas of concern and monitors progress towards goal
Interact with contracting and provider relations to ensure coordinated approach to delivery system providers
Support plan accreditation efforts as determined by Quality Management and Accreditation Team
MD or DO required.
Must be licensed to practice in MA.
Board-certified in their medical specialty, required.
Must be clear of any sanctions by the applicable state or Office of the Inspector General.
Must be eligible to participate in any federally or State funded healthcare programs.
Utilization management experience required.
5 or more years of medical management and general management experience in a managed care environment is strongly preferred.
2 or more years full-time experience practicing medicine 3 or more years in a combination of the following:
o Full-time experience as an administrator in a Medicare or state-level Medicaid program, Health Maintenance Organization (HMO)
o Preferred Provider Organization (PPO), large Health Care Organization, health plan or any combination thereof
Primary care discipline, prior experience as Associate Medical Director (or equivalent) or physician reviewer in a Managed Care Plan preferred.
Minimum five years of progressive business experience.
Standard office environment
English, bilingual preferred not required
Standard office equipment
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