Medical Director - Utilization Management

oilandgasjobsearch.com; Pittsburgh (Allegheny County); Remote; USD 200,000 - 250,000; Full time

Job summary

A leading health care provider is seeking a Medical Director for Utilization Management. This fully remote role involves overseeing quality and utilization standards and ensuring effective collaboration between the health plan and healthcare providers. The ideal candidate will possess a medical degree, have extensive clinical experience, and be licensed in Pennsylvania. This position emphasizes improving member satisfaction and compliance with established guidelines.

Qualifications

• 5-10 years of clinical experience.
• Managed care experience.
• Pennsylvania medical license.

Responsibilities

• Participate in daily utilization management and quality improvement review processes.
• Provide expedited review for medically pressing issues.
• Communicate and educate providers on clinical guidelines.
• Contribute to process improvement within the department.

Skills

Clinical experience

Managed care experience

Communication skills

Education

Doctor of Medicine (MD) or Doctor of Osteopathy (DO)

Job description

Overview

The Medical Director, Utilization Management is responsible for assuring physician commitment and delivery of comprehensive high-quality health care to UPMC Health Plan members. This fully remote role will be responsible for assuring physician commitment and delivery of comprehensive high quality health care to UPMC Health Plan members. Oversees adherence to quality and utilization standards through committee delegations, and further establishes an effective working relationship between UPMC Health Plan's Network and its physicians, hospitals and other providers.

Responsibilities

• Actively participates in the daily utilization management and quality improvement review processes, including concurrent, prospective and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns.
• Provide expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan.
• Keep current with accepted standards and professional developments in the areas of quality improvement and utilization management.
• Communicate and educate network providers regarding clinical guidelines, pathways, protocols, and standards related to quality and utilization processes.
• Interacts with physicians regarding opportunities to improve member satisfaction and compliance with Utilization Management and Quality Improvement policies and procedures.
• Contributes to process improvement within the Utilization Management department.
• Participates in activities to support policy decision making.
• Utilizes clinical experience to support departmental reviews.

Qualifications

This position requires a Doctor of Medicine or Doctor of Osteopathy from an accredited school, and a Pennsylvania medical license. The ideal candidate will have 5-10 years of clinical experience, as well as managed care experience.

Licensure, Certifications, and Clearances

• Doctor of Medicine (MD) OR Doctor of Osteopathic Medicine (DO)

UPMC is an Equal Opportunity Employer/Disability/Veteran