Medical Director - Utilization Management/Care Management

Physician Pivot; Murray (UT); On-site; USD 332,000 - 377,000; Full time

Benefits offered by this job

Sign-on bonus

Relocation bonus

Job summary

Select Health in Murray, Utah seeks an experienced Medical Director of Utilization Management and Care Management to lead clinical UM/CM functions, ensuring high-quality, efficient, and compliant care. You will drive policies, workforce leadership, and collaboration with vendors and providers to achieve outcomes.

The role emphasizes data-driven oversight, performance metrics, and strategic initiatives to reduce unnecessary services while improving patient care and regulatory alignment.

Qualifications

• MD/DO degree with Board Certification in Internal Medicine, Pediatrics, Family Practice, Psychiatry or Emergency Medicine.
• Requires current MD or DO licensure within the states Utah, Idaho, Nevada or Colorado.

Responsibilities

• Lead UM and CM strategies and operations from a clinical perspective.
• Develop and enforce UM/CM policies, procedures and protocols to meet regulatory and accreditation requirements.
• Oversee provider reviewers, concurrent reviews, prior authorizations, medical claims reviews, appeals and grievances.
• Identify process improvements and implement optimized workflows and automation to reduce administrative burden.
• Participate in risk-based contracting and other value-based care initiatives to improve efficiency and reduce abrasion for members and providers.
• Monitor utilization trends, productivity metrics, and report on cost savings and quality outcomes.
• Build and maintain relationships with vendors and clinical teams to improve care quality and efficiency.
• Ensure compliance with state/federal regulations and accreditation standards; educate providers as needed.
• Provide executive leadership to UM/CM staff and support workforce planning.
• Lead special projects to improve member/provider experience and support clinical decision making.

Skills

Leadership

Communication

Taking Initiative

Performance management

Process Improvements

Teamwork

Workflow optimization

Process documentation

Health plan operation

Regulatory knowledge

Education

MD/DO with board certification

Job description

Job Description

Select Health, a regional health plan with over a million members serving all lines of business in Utah, Idaho, Nevada and Colorado, is seeking an experienced Medical Director with expertise in Utilization Management (UM), Care Management (CM) and Health Plan accreditation and other operational and regulatory functions. The Medical Director of Utilization Management/Care Management, reporting directly to the Chief Medical Officer, leads the UM and CM functions for Select Health from a clinical perspective, ensuring that care services are high quality, appropriate, efficient and in compliance with regulatory and accreditation standards. The role combines oversight of the UM and CM functions with Select Health strategies to ensure members receive coverage and services for high-quality, appropriate, efficient, and cost-effective care.

Essential Functions

Key Responsibilities

• Strategic Leadership: Develop and implement UM and CM strategies using data analytics, technology, and cost-benefit analysis to optimize covered services and care management efforts.
• Policy & Process Development: Participate in the creation, revision and enforcement of UM/CM policies, procedures, and protocols to meet regulatory and other accreditation requirements.
• Operational Oversight: From a clinical perspective, manage provider reviewers, concurrent reviews, prior authorizations, medical claims reviews, appeals, and grievances and ensure timely and accurate service authorizations consistent with regulatory and accreditation standards.
• Efficiency & Innovation: Identify process improvements, redesign workflows, and implement processes including auto-approvals, alternative site criteria evaluation, artificial intelligence solutions and prior authorization efficiency where appropriate to reduce administrative burden.
• Pro-Active Care (Value-based Care): Participate in system innovation opportunities such as risk-based contracting, appropriate reduction of prior authorization or other identified opportunities to affect administrative simplification and reduce abrasion for members and providers.
• Data & Trend Analysis: Monitor utilization trends, measure productivity metrics, and report on cost savings and quality outcomes across areas of responsibility.
• Provider & Vendor Management: Build and maintain strong relationships with such Select Health required vendors and clinical teams necessary to improve care quality and efficiency.
• Compliance & Quality: Ensure adherence to state/federal regulations, accreditation standards, and contractual obligations; conduct provider education and training as necessary to facilitate compliance and adherence to quality measures.
• Team Leadership: Supervise and mentor UM/CM staff, provide executive-level guidance, and support workforce planning as needed.
• Special Projects: Lead initiatives to improve member/provider experience, reduce unnecessary services, and enhance clinical decision support.

Skills

• Leadership
• Communication
• Taking Initiative
• Performance management
• Process Improvements
• Teamwork
• Workflow optimization
• Process documentation
• Health plan operation
• Federal, state and local regulations
• Computer Literacy

Additional Details

• FTE: 1.0
• Salary: $332,300 - 377,400 based on relevant experience
• Eligible for an annual leadership incentive opportunity based on system goals
• In addition to the annual salary, to show our commitment to you and assist with your transition, we may offer a sign-on and relocation bonus when applicable.

Minimum Qualifications

• Medical Doctor or Doctor of Osteopathic Medicine degree with Board Certification in one of the following areas: Internal Medicine, Pediatrics, Family Practice, Psychiatry or Emergency Medicine.
• Requires current MD or DO licensure within the State of Utah, Idaho, Nevada or Colorado
• Five years of experience in clinical practice.

Preferred Qualifications

• Utilization management, care management and/or experience in policy related work for a health plan or managed care organization.
• Previous management experience.
• Experience with financial and medical expense management.
• Understanding of health care delivery system as it relates to government programs and agencies.
• Excellent communication skills including ability to establish and maintain rapport with coworkers, providers, brokers, employers, plan members, representatives/executives from other health care entities, government and regulatory bodies and others in the community.

Physical Requirements

• Ongoing need for employees to see and read information, documents, monitors, identify equipment and supplies, and be able to assess member, provider, and coworkers' needs.
• Frequent interactions with colleagues and providers require employees to verbally communicate as well as hear and understand spoken information, needs, and issues quickly and accurately.
• Frequent computer use for typing, accessing needed information, etc.

Location:

SelectHealth - Murray

Work City

Murray

Work State

Utah

Scheduled Weekly Hours

36

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

$70.00 - $999.99

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

All positions subject to close without notice.