Medical Director, Care Quality & Utilization Strategy

QuickCruit; Bothell, Northern (WA, KY); Hybrid; USD 120,000 - 170,000; Full time

Job summary

QuickCruit seeks an experienced leader to oversee medical necessity evaluations and utilization management for plan members. You will ensure services are appropriate and cost-effective while guiding the care setting that yields the best outcomes.

You will educate providers, participate in accreditation activities, and lead initiatives to maintain high-quality member care in alignment with NCQA and URAC standards.

Responsibilities

• Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization.
• Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.
• Assumes leadership relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity.
• Participates in and maintains the integrity of the appeals process, both internally and externally.
• Responsible for investigation of adverse incidents and quality of care concerns.
• Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications.

Job description

QuickCruit seeks an experienced leader to oversee medical necessity evaluations and utilization management for plan members. You will ensure services are appropriate and cost-effective while guiding the care setting that yields the best outcomes.

You will educate providers, participate in accreditation activities, and lead initiatives to maintain high-quality member care in alignment with NCQA and URAC standards.