Medical Director - UM Optimization
Core
Provide medical leadership for Utilization Management (UM), cost containment, and quality improvement activities, evaluating data to optimize UM processes and support the Chief Medical Officer.
Role type
Senior IC Medical Director (Utilization Management)
Builds
Strategic UM processes, cost containment programs, and quality improvement initiatives for capitated providers.
Domain
Healthcare / Managed Care / Utilization Management
Required skills
Utilization Management expertise, Medical review of complex cases, Strategic planning, Data analysis, Provider network development, Clinical quality improvement, Regulatory compliance, Physician committee management, Medical necessity determination, Provider education
Preferred skills
Payer/Managed Care experience, Health Administration knowledge, Experience with culturally diverse populations, Board certification in Psychiatry
Technologies
None stated
Responsibilities
Provide medical leadership for utilization management and cost containment activities. Perform medical review activities for utilization review and quality assurance. Support implementation of performance improvement initiatives for capitated providers. Assist in planning goals and policies to improve quality and cost-effectiveness. Provide medical expertise for quality improvement and utilization management programs. Function in physician committees regarding structure and processes. Conduct regular rounds to assess and coordinate care for high-risk patients. Collaborate with clinical teams and consultants for reviewing complex cases and appeals. Participate in provider network development and new market expansion. Develop and implement physician education on clinical issues and policies. Identify utilization review studies and evaluate adverse trends in service utilization. Identify clinical quality improvement studies to reduce unwarranted variation. Interface with providers to facilitate implementation of recommendations. Review claims involving complex or new services to determine medical necessity. Develop alliances with the provider community through medical management programs. Represent the business unit before various publics and state committees.
Seniority
Senior, hands-on IC