Medical Director, Utilization Management Physician - WellMed - Remote

Optum; Jacksonville (FL); Remote; USD 250,000 - 300,000; Full time

Job summary

Optum, a leader in healthcare innovation, seeks a Medical Director for Utilization Management to join their team in Jacksonville, Florida. This pivotal role involves setting standards for utilization management, ensuring compliance, and enhancing the health plan members' care experience through strategic program development and physician collaboration. With the flexibility to work remotely, you'll leverage your clinical expertise in a dynamic, supportive environment focused on health improvement.

Qualifications

• MD or DO with experience in internal or family medicine.
• Proficient in CMS criteria and utilization management processes.
• Active participation in physician meetings and compliance assurance.

Responsibilities

• Develop and maintain an efficient UM program.
• Conduct case reviews and medical necessity determinations.
• Oversee compliance with UM plans.

Skills

Clinical resources

Utilization management

Compliance regulations

Education

Medical degree (MD or DO)

Job description

WellMed, part of the Optum family of businesses, is seeking an internal medicine or family medicine physician to join our Utilization Management team. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.

At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

The Medical Director for Utilization Management will support WellMed Medical Management, Inc. by making utilization management determinations, identifying utilization trends suggesting possible over or under utilization of services and proactively suggesting improvements to WellMed Medical Management’s utilization management program.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Position Highlights & Primary Responsibilities:

• Assists in development and maintaining an efficient UM program to meet the needs of the health plan members and commensurate with company values
• Remain current and proficient in CMS criteria hierarchy and organizational determination processes
• Participates in case review and medical necessity determination
• Maintain proficiency in compliance regulations for both CMS and delegated health plans
• Conducts post service reviews issued for medical necessity and benefits determination coding
• Assists in development of medical management, care management, and utilization management protocols
• Performs all other related duties as assigned.

Customer Service

• Oversees and ensures physician compliance with UM plan
• Performs all duties in a professional and responsible manner
• Responds to physicians and staff in a prompt, pleasant and professional manner
• Respects physician, patient, and organizational confidentiality
• Provides quality assurance and education of current medical technologies, review criteria, accepted practice of medicine guidelines, and UM policies and procedures with counsel when criterion are not met

Personal and Physician Development

• Strives to personally expand working knowledge of all aspects of the UM department
• An active participant in physician meetings
• Orients new physicians to ensure understanding of company policy and resources available for physician support
• Assists in the growth and development of subordinates by sharing special knowledge with others and promotes continued education classes