Associate Medical Director Utilization Review

Fallon Health
July 28, 2022
Job Type
Work Setting


This position works with both inpatient and outpatient Care Management nurses to monitor appropriate care and services in hospitals, skilled nursing facilities and home care settings to ensure quality, cost-effectiveness and continuity of care. Also works with both inpatient and outpatient care managers on individual member cases to ensure the effectiveness of care management programs. Participates in physician reviewer and preauthorization meetings to coordinate and assure consistent application of FCHP guideline criteria; also to assure appropriate administration of member benefits as outlined in individual product line Evidence of Coverage Handbooks and the Benefits Manual.


Primary Job Responsibilities:

  • Provide clinical support for prior authorization process
  • On-site, off-site and telephonic inpatient case management rounds
  • Outpatient case management rounds
  • Provider appeals review
  • Member appeals review
  • Pharmacy issues and referral requests
  • Medical director on-call coverage
  • Support the benefits and technology review process
  • Provide support for UM administrative infrastructure
  • Participate in the HP’s strategic planning process and establish yearly financial goals and monitor progress toward such goals as part of the strategic plan.
  • Develop annual goals and objectives and submit to an annual evaluation by the President.


Education, Licenses, certification and experience requirements:

  • Unrestricted license to practice medicine in MA (or licensable).
  • Board certified in medical or surgical specialty.
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