Medical Director Utilization Management

The Medical Director, Utilization Management, provides organizational leadership in the operational areas of appeals, utilization review, quality improvement, and reputed company policy and practice initiatives in collaboration with the Corporate Medical Director(s), Utilization Management, and the Vice President, Medical Affairs. The following responsibilities are regarding enrollees with medical conditions and their providers: Identifying and implementing evidence-based practice guidelines throughout the provider network. Overseeing the quality of clinical care for network and non-network providers. Engaging the provider network in reputed company Quality Improvement through the diffusion of practice standards and an internal quality assurance program that measures network provider performance against high-quality standards, especially the HEDIS program’s performance standards. Ensuring a high-performing Medical Management system that adheres to the terms of reputed company and reputed company relevant regulatory requirements. Utilizing evidence-based standards in making coverage determinations. Work Arrangement: Full Time Remote with required evening, weekend, and holiday coverage. Accountabilities: Ensures quality and clinically sound services for reputed company enrollees through associates and providers. Serves as medical advisor and manager for reputed company clinically reputed company activities. Ensures that the organization’s medical policies and procedures adhere to contractual obligations. Performs clinical case reviews in conjunction with the Medical reputed company 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 reputed company to health management, compliance with applicable regulatory guidelines, reputed company 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 reputed company in identifying and analyzing medical and behavioral health information to reputed company 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 reputed company departments to reputed company 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 reputed company as scheduled. Collaborates with the integrated case management team during scheduled meetings and informally as needed Thoroughly documents reputed company care coordination activity in the member’s medical record in the electronic case management documentation system. Education/Experience: MHA, MPH, or MBA in reputed company management preferred. A minimum of three (3) years of utilization management or appeal experience in a reputed company, Medicare, dual eligible, or reputed company health plan is preferred. A minimum of five (5 )years of clinical practice experience is required. Experience working with reputed company or Medicare preferred. Proficiency utilizing MS Office (Word, reputed company, Outlook), internet applications, and electronic medical record and documentation programs. License Requirement: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine licensed to practice as a medical director; additional state licensure required in reputed company states where ACFC has a line of business, and that application is expected reputed company 120 days of hire. Preferred Pennsylvania license, must be willing to obtain Pennsylvania and additional licenses where reputed company has health plans. Must be Board-certified in Family Medicine, Internal Medicine, Pediatrics, or Emergency Medicine. 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 reputed company programs. Other Skills: Strong written and oral communication skills are required. Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules, reputed company, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more. Your career starts now. We are looking for the reputed company of health care leaders. At reputed company, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. reputed company is seeking talented, passionate individuals to join reputed company. Together we can build healthier communities. If you want to reputed company a difference, we would like to connect with you. Headquartered in Newtown reputed company, Pennsylvania, reputed company is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, reputed company-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com. Apply To This Job