Lead Medical Director, Utilization Management
Core
Lead Medical Director responsible for evaluating outpatient referrals and inpatient admissions for medical necessity, managing a team of Utilization Management Medical Directors, and developing clinical policies.
Role type
Senior IC medical director (utilization management)
Builds
Clinical policies, medical necessity criteria, and utilization management workflows
Domain
Healthcare insurance / Utilization management
Required skills
Clinical judgment, evidence-based guidelines knowledge, regulatory compliance, team leadership, policy development, committee management, conflict resolution, data analysis
Preferred skills
Board certification in relevant specialty, experience with Medicare coverage determinations, experience with Milliman Care Criteria
Technologies
Clover Assistant, Milliman Care Criteria, Medicare Coverage Determinations
Responsibilities
Complete prior authorization, concurrent, and retrospective UM cases; manage a team of Utilization Management Medical Directors; develop and maintain clinical policies and procedures; chair the Utilization Management Committee; serve on Credentialing and Quality Committees; participate in peer-to-peer discussions and appeals; use audit findings to improve policies and workflows; advise organizational leaders on UM strategy.
Seniority
Senior, hands-on IC with leadership responsibilities