Medical Director, Utilization Management- CFHP

University-Health-3; San Antonio (TX); In loco; USD 153.000 - 205.000; Tempo pieno

Descrizione del lavoro

Community First Health Plans (CFHP) seeks a Medical Director for Population Health Management in Texas. You will lead utilization management across multiple product lines and ensure compliant, timely decisions aligning with CFHP’s mission and Triple Aim Plus objectives.

The role requires an MD/DO with Texas licensure, board certification, and at least 5 years of clinical care experience, including leadership in managed care. Inpatient, LTAC, and Nursing Facility exposure is preferred.

Competenze

• Medical degree (MD/DO) and active Texas Medical License, free of sanctions.
• Minimum 5 years of direct clinical patient care after residency.
• Leadership experience in managed care and knowledge of utilization review and quality management.

Mansioni

• Provide clinical leadership and oversight for utilization management across multiple product lines.
• Ensure determinations are accurate, timely, and compliant with standards and policies.
• Collaborate across departments to drive quality, efficiency, and integrated care delivery.

Conoscenze

Clinical leadership

Utilization management

Population health

Regulatory compliance

Formazione

MD or DO

Texas Medical License

Board certification

Descrizione del lavoro

Community First Health Plans

Population Health Management - CFHP

Full Time

Day Shift

Salary Range: $111.00 - $149.04

POSITION SUMMARY/RESPONSIBILITIES

Reporting to the Chief Medical Officer, this position provides clinical leadership and oversight for utilization management activities across multiple product lines. while supporting the multidisciplinary member centric approach to care management. This role ensures all determinations are accurate, timely, and compliant with regulatory standards, contractual requirements, and health plan policies while promoting a member-centric approach aligned with Community First Health Plans, Inc., (Community First) mission, vision, and Triple Aim Plus objectives, improving population health outcomes, enhancing member experience, containing costs, and improving access to care. The Medical Director collaborates across departments to drive quality, efficiency, and integrated care delivery.

EDUCATION/EXPERIENCE

A medical degree as Doctor of Medicine (MD) or Osteopathy (DO) and an active and unrestricted Texas Medical License, free of sanctions from Medicaid or Medicare is required. A m inimum of five years of direct clinical patient care experience post residency is required. Clinical experiences in inpatient, LTAC, and Nursing Facility setting are preferred. A minimum of two years' experience in population health management is preferred. Prior leadership position in managed care, with a comprehensive understanding of utilization review and quality management procedures, including Medicaid, Medicare, Commercial and Marketplace programs, is highly desirable. A primary care specialty is also preferred.

LICENSURE/CERTIFICATION

Current unrestricted license as Doctor of Medicine or Osteopathy for Texas is required. Board certification is required.