Medical Director - Benefit/Utilization Management

CareOregon, Inc.; United States; Remote; USD 295,000 - 360,000; Full time

Benefits offered by this job

Total rewards program

Bonus opportunity

Comprehensive benefits package

Job summary

CareOregon is seeking a Medical Director - Benefit/Utilization Management to oversee clinical and wellness programs for members. You will lead utilization, case, disease, and quality management initiatives and collaborate with network providers to improve care delivery and outcomes.

The role requires MD/DO licensed in Oregon with board certification in primary care, and a track record of leadership in managed care and quality assurance.

Qualifications

• MD/DO licensed in Oregon
• Board-certified in primary care (Internal Medicine/Family Practice/OBGYN/Pediatrics)
• Minimum 3 years physician experience
• Minimum 4 years supervisory experience (preferred)
• Benefit/utilization management experience (preferred)
• Leadership experience in managed care, quality assurance, utilization review and case management (preferred)

Responsibilities

• Develop, implement and manage clinical and wellness programs to address member needs.
• Oversee utilization, case, disease, and quality management programs.
• Educate participating physicians on quality and utilization management issues.
• Represent CareOregon in medical associations and community activities.
• Provide medical leadership for Care Management/Care Coordination activities.
• Oversee medical director responsibilities for medical and pharmacy determinations and appeals.
• Collaborate with CCO/LOB Medical Directors to shape clinical strategy and interventions.
• Educate network providers on best clinical practices using population health data.
• Support and lead cross-functional teams to improve care delivery and outcomes.

Skills

Leadership

Quality improvement

Clinical governance

Utilization management

Communication

Education

MD/DO licensed in Oregon

Board-certified in primary care (Internal Medicine/Family Practice/OBGYN/Pediatrics)

Job description

Medical Director - Benefit/Utilization Management

This position is responsible for oversight of clinical and wellness programs and initiatives in support of CareOregon members. Areas of focus may include benefit management, benefit utilization, quality assurance, case management, disease management, pharmacy, or other areas.

Note: This is a 0.8 position with benefits. The hiring range listed would be pro-rated to reflect 0.8.

Estimated Hiring Range:

$294,570.00 - $360,030.00

Bonus Target:

Bonus - SIP Target, 10% Annual

Essential Responsibilities

• With the Senior Medical Director, develop, implement and manage clinical and wellness programs to address the needs members.
• Implement, direct and oversee utilization, case, disease, and/or quality management programs.
• Develop and implement programs for educating participating physicians regarding quality management and utilization management issues.
• Represent the health plan in applicable activities including medical and other professional organizations.
• Participate in activities that enhance CareOregon’s image within the community.
• Serve as a representative and medical spokesperson for the plan in support of Coordinated Care Organizations (CCOs), contract negotiations and other provider expansion activities.
• Provide leadership necessary to maintain a motivated, productive and competent team through open communication and delegation of responsibilities and authority.
• Provide medical support for Care Management/Care Coordination activities.
• Provide medical director oversight, benefit determinations and appeals for medical and pharmacy as assigned by Senior Medical Director.
• May integrate with CCO/Line of Business (LOB) Medical Directors to develop, implement, direct, and oversee programs that provide clinical strategy and interventions to CCO/LOB clinical systems.
• Support and implement programs for educating network providers regarding best clinical practice using of population/panel management and performance data on clinical quality and utilization.

Experience and/or Education

Required

• Board-certified medical doctor or doctor of osteopathy in one of the primary care specialties, including obstetrics/gynecology (Internal Medicine, Family Practice, Emergency Medicine, or Pediatrics preferred)
• Licensed physician (MD or DO) in the State of Oregon
• Minimum 3 years’ physician experience

Preferred

• Minimum 4 years’ experience in a supervisory position
• Benefit/utilization management experience
• Leadership experience, preferably to include managed care, quality assurance, utilization review and case management experience

Knowledge, Skills and Abilities Required

Knowledge

• Clinical knowledge of the management of diverse medical problems
• Basic knowledge of applicable regulatory and contractual requirements for Medicaid, Medicare and commercial insurance
• Understanding of managed care operations
• Familiarity with guideline development, outcomes management, population health improvement, disease management and cost effectiveness and cost analysis studies
• Awareness of physician/provider payment issues, physician practice models and total quality and continuous quality improvement concepts

Skills and Abilities

• Medical policy knowledge and skills as related to quality, case and disease management, credentialing activities and utilization management
• Excellent communication and collaboration skills for work with network providers and internal employees
• Ability to effectively express ideas and gain their acceptance
• Ability to implement new and improved approaches to improvement of care and service quality, and to Care Management activities performed by CareOregon
• Ability to implement clinical and wellness programs to address the needs of high-risk members
• Ability to work effectively as part of a cross-functional team and foster an environment where change is embraced and supported
• Ability to deal with issues and problems systemically
• Ability to work as an integral part of a team
• Ability to plan, set priorities, delegate effectively and utilize time efficiently
• Ability to apply innovative and creative approaches to improve health care delivery
• Skills in quality management techniques to apply in a large, organized managed care setting
• Commitment to improving access and quality of care to the underserved and uninsured
• Appreciation of cultural diversity and the needs of serving a diverse patient population
• High degree of diplomacy, credibility and persuasiveness to consistently cultivate effective working relationships
• An organized, disciplined, hands‑on and process-oriented leader
• Persistent, assertive, data driven and focused
• Proactive and action oriented; drives performance
• High degree of initiative and motivation along with the ability to effectively support and collaborate with others to achieve business objectives
• Ability to work effectively with diverse individuals and groups
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to hear and speak clearly for at least 3-6 hours/day

Working Conditions

Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure

Member/Patient Facing: ☒ No ☐ Telephonic ☐ In Person

Hazards: May include, but not limited to, physical and ergonomic hazards.

Equipment: General office equipment

Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.

Work Location: Work from home

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks.

We are an equal opportunity employer

CareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.