Medical Director, Utilization Management

Jobtailor; Deutschland; Remote; EUR 120.000 - 180.000; Vollzeit

Zusammenfassung

Jobtailor seeks a Medical Director to provide clinical oversight and lead utilization management and quality improvement across our healthcare network in Germany. The role focuses on aligning care with evidence-based standards and regulatory requirements.

You will develop protocols, monitor performance, and partner with providers and health plan teams to enhance patient outcomes and care coordination. Strong leadership and data-driven decision making are essential.

Qualifikationen

• MD/DO degree, board certification, and active medical license are required.
• Leadership and communication skills are essential for directing clinical programs.
• Experience with utilization management, population health, and value-based care is preferred.

Aufgaben

• Provide clinical oversight and direction to ensure the quality and efficiency of healthcare services.
• Develop and implement clinical protocols, guidelines, and standards.
• Monitor and evaluate clinical performance metrics and outcomes.
• Lead quality improvement initiatives to enhance patient care and safety.
• Oversee evidence-based practices and clinical pathways.
• Review clinical data to identify areas for improvement.

Kenntnisse

Leadership

Communication

Interpersonal skills

Collaboration

Education facilitation

Ausbildung

MD/DO degree

Board certification

Active medical license

Jobbeschreibung

• Provide clinical oversight and direction to ensure the quality and efficiency of healthcare services
• Develop and implement clinical protocols, guidelines, and standards
• Monitor and evaluate clinical performance metrics and outcomes
• Lead quality improvement initiatives to enhance patient care and safety
• Oversee evidence-based practices and clinical pathways
• Review clinical data to identify areas for improvement
• Partner with Quality, Care Management, and Population Health teams to improve HEDIS, Stars, preventive care, care gap closure, and utilization performance metrics
• Support identification and management of high-risk, high-cost, and high-opportunity patient populations through data-driven interventions
• Foster relationships with network physicians and healthcare providers
• Address clinical issues, improve care coordination, and promote best practices with providers
• Facilitate provider education and training programs
• Provide physician leadership for utilization management activities
• Participate in prospective, concurrent, and retrospective utilization reviews, including medical necessity determinations, treatment plans, hospital admissions, and specialty referrals
• Serve as a clinical resource for complex utilization, authorization, and care management cases
• Develop, implement, and refine utilization management policies, procedures, clinical criteria, and authorization guidelines
• Analyze utilization trends, referral patterns, inpatient and outpatient utilization data, and care coordination opportunities
• Participate in appeals and peer-to-peer discussions with health plans and providers
• Provide clinical oversight related to high-risk patient management, transitions of care, and complex case reviews
• Participate in and/or chair Utilization Management Committee meetings
• Present utilization trends, performance metrics, and improvement opportunities to leadership
• Ensure compliance with regulatory requirements and industry standards
• Manage audits and accreditation processes
• Contribute to the IPA's strategic plan and identify growth opportunities
• Participate in network expansion, provider recruitment, retention, interviews, onboarding, and orientation
• Serve as AMG Friendly Physician for the Southern California Region

Requirements

• MD or DO degree from an accredited medical school
• Active and unrestricted medical license
• Minimum of 5 years of clinical experience, with at least 3 years in a leadership role
• Board certification in a medical specialty
• Strong understanding of quality improvement methodologies and healthcare regulations
• Excellent communication, leadership, and interpersonal skills
• Ability to analyze complex clinical data and develop actionable insights
• Strong knowledge of utilization management, care management, population health, and value-based care principles
• Ability to conduct medical necessity reviews and evaluate clinical appropriateness using evidence-based guidelines
• Experience managing provider appeals, authorization reviews, and payer interactions
• Understanding of HEDIS, Stars, RAF, quality incentive programs, and managed care performance metrics
• Demonstrated ability to influence physician behavior through education, collaboration, and data-driven performance improvement
• Experience in an IPA, health plan, ACO, delegated medical group, managed care, or value-based care environment strongly preferred
• Prior experience serving as a Medical Director, Associate Medical Director, or Physician Advisor supporting utilization management, care management, population health, or quality programs preferred
• Experience working with delegated managed care arrangements, health plan partners, and utilization management committees preferred
• External hires must pass a background check/drug screen

Core Competencies

Demonstrates expertise in clinical oversight, utilization management, and quality improvement within healthcare settings. Proficient in analyzing clinical data, developing protocols, and fostering provider relationships to enhance patient care and safety.

Highest-signal resume keywords

• MD Or DO Degree
• Active And Unrestricted Medical License
• Board Certification In A Medical Specialty
• Utilization Management Experience
• Quality Improvement Methodologies

ATS Optimization Keywords

Hard Skills

• Clinical Protocol Development
• Clinical Performance Metrics Analysis
• Evidence-Based Practice Oversight
• Medical Necessity Reviews
• Data-Driven Interventions
• Care Coordination
• Utilization Review Participation
• Clinical Data Analysis
• HEDIS Knowledge
• Quality Incentive Programs Understanding

Soft Skills

• Excellent Communication Skills
• Leadership Skills
• Interpersonal Skills
• Collaboration Skills
• Education Facilitation

Certifications & Qualifications

• Board Certification In A Medical Specialty

Industry Keywords

• Utilization Management
• Population Health
• Value-Based Care
• Managed Care
• IPA
• ACO
• Quality Improvement
• Care Management
• Healthcare Regulations
• Clinical Pathways