Description
Reporting to the Senior Medical Director of Medical Policy and Utilization Review, the Utilization Review Medical Director will be responsible for providing leadership and subject matter expertise to our utilization management (UM) group. This role is a key role in helping our organization provide high quality, equitable care to our rapidly growing membership. The incumbent will have significant experience with utilization review, ideally experience with public programming, and excellent clinical judgment. They will work well both independently and in conjunction with a diverse team, improving operations and efficiency, using excellent communication skills to interact with professionals internally and externally.
Essential Duties & Responsibilities
- Primary responsibility for performing daily medical reviews, appeals as appropriate, correspondence regarding review determinations and physician peer review activities.
- Discuss specific clinical issues with attending physicians and CCA clinicians
- Document case review findings, actions, and outcomes in accordance with Utilization.
- Management policies; meets health plan inter-rater reliability guidelines.
- Appropriately access clinical specialty panel physicians to assist in complex or difficult case.
- Ensure compliance with medical policy. Maintains compliance with all federal, state, and local regulatory guidelines.
- Serve as the lead for CCA’s Utilization Review functions working closely with other medical management team members.
- Support the development of utilization management policy initiatives.
- Support the development and implementation of medical policy, including recommendations for modifications to enhance efficiency and effectiveness.
- Partner with the VP of UM to direct the efforts of the utilization review and pre-certification functions to accomplish objectives within policy and budget.
- Serve as a clinical resource and coach for the utilization management team.
- Is available and accessible to the utilization management team throughout the day to respond to clinical issues.
- Monitor utilization reports, identifying changes in utilization or access patterns and monitor overall trends on a weekly basis.
- Provide education to internal care management and clinician staff.
- Provide clinical input to specific projects as required by the organization or vendors.
- Maintain working knowledge of current quality improvement issues and tools.
- Contribute to development of Medical Expense Action plans to implement tactics to address areas of concern and monitors progress towards goal.
- Interact with contracting and provider relations to ensure coordinated approach to delivery system providers.
- Support plan accreditation efforts as determined by Quality Management and Accreditation Team.
- Support teams and track Key Performance Indicators (KPI) related to clinical care for members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
Required Education
- MD or DO required.
- Must be licensed to practice in MA.
- Board-certified in their medical specialty, required.
- Must be clear of any sanctions by the applicable state or Office of the Inspector General.
- Must be eligible to participate in any federally or State funded healthcare programs.
Required Licensing
- Must be licensed to practice in MA.
- Board-certified in their medical specialty, required.
MA Health Enrollment (required if licensed in Massachusetts)
- Yes, this is required if the incumbent is licensed in Massachusetts.
Required Experience
- Utilization management experience required.
- 2 or more years full-time experience practicing medicine.
- 3 or more years in a combination of the following: (a) Full-time experience as an administrator in a Medicare or state-level Medicaid program, Health Maintenance Organization (HMO); and (b) Preferred Provider Organization (PPO), large Health Care Organization, health plan or any combination thereof.
- Minimum five years of progressive business experience.
Desired Experience
- 5 or more years of medical management and general management experience in a managed care environment is strongly preferred.
- Primary care discipline, prior experience as Associate Medical Director (or equivalent) or physician reviewer in a Managed Care Plan preferred.
Required Knowledge, Skills & Abilities
- Ability to work well both independently and in conjunction with a diverse team, improving operations and efficiency.
- Excellent communication skills to interact with professionals internally and externally.
- Able to support teams with utilization of telehealth technologies (video, chat, etc.), when appropriate, as an approved modality for a variety of clinical care and care management services.
Required Language
- English.
Desired Knowledge, Skills, Abilities & Language
- Bilingual preferred.