The Medical Director with Southwestern Health Resources will act as the primary medical resource, within Utilization Management (UM), to keep patients safe, improve quality, and combat fraud, waste and abuse. The Program Director will perform timely physician level reviews for medical necessity determinations, quality evaluation, and other utilization management evaluation as needed. The Program Director will leverage UM program detail, Health Plan information, and other tools to provide individualized analysis to providers and facilities and suggest program development or modification within Utilization Management (UM) to improve member outcomes. The Program Director will maintain a consistent high level of service and effective relationships with the UM Department staff, physicians, hospitals and medical service companies. The incumbent is accountable for quality and value management of all product lines and services.
The essential job functions of this position are:
• Assists with oversight of clinical decision making aspects of the UM program, with the goals of keeping patients safe, improving quality of care, and enhancing affordability of care.
• Reviews and decides UM cases, reducing waste, ensuring that all requests for services and resources meet medical necessity criteria, and are medically prudent.
• Participates in peer to peer discussions with physicians requesting pre-certifications/ authorizations or other medical necessity determinations.
• Provides guidance for clinical operational aspects of the program.
• Actively participates/ facilitates Quality and Utilization Management Committees.
• Participates in setting policies and procedures for the Utilization Management department.
• Collaborates with internal and external entities to improve accessibility standards and quality practice standards to enhance value across the service delivery system (inpatient, emergency departments, urgent care services and practitioner office settings).
• Maintains a mutually professional relationship with physicians, hospital personnel, social services, agencies, etc.
• Assists in ensuring that Utilization Management Program policies and procedures meet regulatory requirements.
• Maintains relationships with key leaders and works to support their business strategies.
• Is accountable for the overall quality and affordability of care of the clinical programs and processes in concert with the VP of Expense Management.
• Is responsible for compliance with the policies and procedures, the standards of accrediting bodies and the regulations of state and local governing agencies.
• Is accountable for clinical excellence in providing managed care services that focus on quality patient care, timely provision of services, and cost-effectiveness.
• Comply with all compliance, regulatory and process training within the specified timeline.
• Perform other duties as assigned.
The ideal candidate will possess the following qualifications:
• Graduate of an M.D. or D.O. program required.
• 5 years of general medical clinic practicing physician experience required.
• 5 years of board certified medical specialty or medical practice experience preferred.
• 2 years of Utilization Management experience including MA medical review, peer to peer, and physician/ facility liaison functions preferred.
• MD - Medical Doctor State of Texas, DO - Doctor of Osteopathic Medicine State of Texas, or other American Board of Medical Specialty Certification in respective area required upon hire.
• Strong analytical and organizational skills.
• Knowledge of Medicare, Medicaid, and Commercial Coverage Criteria.
• Knowledge of specific regulatory and managed care requirements.