CMO, Utilization Management & Medical Policy

UPMC; Pittsburgh (Allegheny County); Sur place; USD 350 000 - 700 000; Plein temps

Résumé du poste

UPMC is seeking a senior leader to serve as the Chief Medical Officer of the Insurance Services Division (ISD). Under the CMO, this role provides medical leadership for clinical and quality strategies, oversees physician utilization management and medical policy teams, and leads provider benchmarking and performance improvement across commercial products.

You will collaborate with IDFS clinical partners, ensure compliance with accreditation and state/federal regulations, manage physicians and

Responsabilités

• Contribute clinical and operational expertise to Division CMO, CEO and all senior management activities at the Insurance Services Division.
• Manage the development, implementation, and provision of ongoing clinical evaluation of the lines of business as assigned.
• Oversee the development, implementation and ongoing evaluation of clinical resource management programs and community-based programs.
• Oversee the standardization of practice patterns and the achievement of desired outcomes through clinical resource management and provider benchmarking.
• Oversee and supervise the Medical Policy team to insure timely, evidence-based, data-driven development and implementation of appropriate medical policies, both pre-service and post-service, to ensure the members receive coverage for clinically appropriate services in the most cost effective level of care.
• Oversee the physician Medical Director team to ensure compliance with all regulatory requirements, appropriate interpretation of medical policies, consistent implementation of utilization management criteria across all lines and collaboration across the IDFS as well as other network and non-network facilities.
• Provide support of the provider relations activity of the lines of business as assigned. Supervise and guide the Medical Directors in identified lines of business in regards to meeting and exceeding standards or benchmarks for quality care and establish benchmarks or standards as needed.
• Represent UPMC Insurance Services Division at various internal and external meetings/conferences.
• Develop and cultivate strong working relationships with regulatory entities.
• Participate in the strategic planning of the UPMC Insurance Services Division.
• Exemplify a collaborative approach to work ethic for staff to model.
• Establish and monitor the appropriate budget as assigned. Select, retain, develop, and reward a competent staff.
• Develop strategies to foster external relationships (including state and federal agencies)
• Recommend annual plan along with the strategies, tactics and resources necessary to achieve division goals and objectives directly related to the essential functions of the position.

Description du poste

UPMC is seeking a senior leader to serve as the Chief Medical Officer of the Insurance Services Division (ISD). Under the CMO, this role provides medical leadership for clinical and quality strategies, oversees physician utilization management and medical policy teams, and leads provider benchmarking and performance improvement across commercial products.

You will collaborate with IDFS clinical partners, ensure compliance with accreditation and state/federal regulations, manage physicians and