Medical Director-Medicaid (ABH VA)
Core
Medical Director leading utilization management, prior authorization, and clinical decision support for Medicaid members across multiple US states.
Role type
Senior Medical Director (Utilization Management)
Builds
Clinically sound utilization management decisions and peer-to-peer consultations for Medicaid managed care plans.
Domain
US Healthcare / Medicaid Managed Care
Required skills
Utilization management, prior authorization, concurrent review, peer-to-peer consultation, medical necessity review, first-level appeal determinations, acute and post-acute care review, multidisciplinary collaboration
Preferred skills
Board certification in Family Medicine, Emergency Medicine, or Internal Medicine-Pediatrics, Utilization Management experience with health plans or IROs, Medicaid managed care experience, experience with electronic health records
Technologies
Electronic health records, clinical documentation systems
Responsibilities
Conduct utilization management and medical necessity reviews; determine prior authorization and precertification; perform concurrent reviews for inpatient and outpatient services; review acute and post-acute care; conduct peer-to-peer consultations with treating providers; perform pharmacy reviews and first-level appeal determinations; collaborate with multidisciplinary clinical and operational teams; participate in rotating on-call schedule including weekends and holidays
Seniority
Senior, hands-on IC with leadership responsibilities