Medical Director Utilization Management

Skills

About the Role

You will support the clinical content team in reviewing the company's clinical decision guidelines and evidence based literature. You'll provide expert input on content to influence physicians in medical care and improve the quality of patient outcomes. You'll deliver timely medical reviews that meet stringent quality and timeliness parameters, and provide clinical determinations based on evidence-based criteria while utilizing your clinical acumen and knowledge of medical society guidelines. You'll document all communication and decision-making clearly in workflow tools using correct templates, and conduct timely peer-to-peer discussions with treating providers to clarify clinical information and explain review outcomes. You'll demonstrate professionalism and accountability in your interactions with teammates and providers, and support projects and operational improvements as delegated.

Requirements

• Completed US-based residency program and fellowship in Internal Medicine
• Board certification as an MD or DO with a current unrestricted state license to practice medicine
• 5+ years of clinical practice beyond residency/fellowship in Internal Medicine
• Excels in a matrix organization
• Comfortable with technology - willing and able to learn new software tools
• Understanding of managed care regulatory structure and processes
• Detail-oriented, flexible, and able to work autonomously with little supervision
• 1+ years of managed care utilization review experience desirable
• Membership in national and/or regional specialty societies preferred
• Licensure in AZ, GA, MS, NC, ND, OK, OR, or TX is highly desirable

Responsibilities

• Support the clinical content team in reviewing the company's clinical decision guidelines and evidence based literature
• Provide expert input on content for influencing physicians in medical care to improve the quality of patient outcomes
• Provide timely medical reviews that meet stringent quality and timeliness parameters
• Provide clinical determinations based on evidence-based criteria while utilizing clinical acumen and knowledge of evidence based literature and medical society guidelines
• Clearly and accurately document all communication and decision-making in workflow tools
• Use correct templates for documenting medical necessity decisions during case review
• Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and explain review outcome decisions
• Demonstrate the highest level of professionalism, accountability, and service in interactions with teammates and providers
• Support projects specific to building the team's clinical expertise and efficiency, as delegated
• Support the team on operational improvements and member/provider experience involving clinical review tasks, as delegated

Benefits

• Medical, dental, vision, life, disability insurance, and Employee Assistance Program
• 401K retirement plan with company match
• Flexible spending and health savings account
• Flex Time Off + company holidays
• Up to 14 weeks of paid parental leave
• Pet insurance