Medical Director, Utilization Management (Remote)

UPMC; Pittsburgh (Allegheny County); Remote; USD 180,000 - 240,000; Full time

Job summary

UPMC Health Plan is seeking a Medical Director, Utilization Management, to lead credentialing and drive quality improvement across the network of physicians and providers. This fully remote role ensures timely medical decisions and adherence to utilization standards.

You will oversee payer-provider collaboration, after-hours support, and external accreditation activities while advancing member care outcomes and organizational goals.

Qualifications

• Experience leading provider credentialing processes.
• Ability to oversee quality improvement and utilization management.
• Proven track record in collaborating with physicians and health plans.

Responsibilities

• Provide leadership for credentialing processes.
• Direct leadership for CHC-MCO utilization decisions, including after-hours as needed.
• Lead quality improvement and care management goals directed at improving member health outcomes.
• Review and determine medically pressing issues per Health Plan policies.
• Participate in daily utilization management and quality improvement reviews.
• Stay current with accepted standards in quality improvement and utilization management.
• Educate network providers on guidelines, pathways, protocols, and standards.
• Report communicable diseases as required by statute.
• Collaborate with epidemiologists and health department staff.
• Support daily QI and UM program activities.
• Represent the Health Plan in external accreditation activities.
• Act as first-level physician reviewer for cases referred by QI/UM departments.
• Maintain effective relationships between the Network and providers.

Skills

Leadership

Healthcare management

Quality Improvement

Utilization management

Provider credentialing

Communication with providers

Job description

Purpose

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.

UPMC offers a premier benefits package, designed to care for your total well-being — physically, emotionally, and financially — paired with endless opportunities for career advancement and growth. Discover the culture, the teams, and the passions that drive us to make Life Changing Medicine happen.

Responsibilities

• Provide leadership direction for provider credentialing processes.
• Physicians must devote sufficient time to the CHC-MCO to provide timely medical decisions, including after-hours consultation, as needed
• Provide leadership and direction in meeting Quality Improvement and Care Management goals directed at improvements in member health status outcomes and established business strategies.
• Provide expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan.
• 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.
• 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.
• Responsible for reporting the communication of reportable communicable diseases in accordance with statute.
• Interacts with physicians regarding opportunities to improve member satisfaction and compliance with Utilization Management and Quality Improvement policies and procedures.
• Work with the DOH State and District Office Epidemiologists in partnership with the designated county/municipal health department staff to appropriately report reportable conditions in accordance with 28 Pa. Code 27.1 et seq.
• Daily interventions support implementation of the Health Plan's Quality Improvement and Care Management Programs.
• Represent the Health Plan in external accreditation and certification activities.
• Act as first level physician reviewer for all cases referred by the Quality Improvement and Care Management Departments.
• Daily activities support adherence to quality and utilization standards and establish an effective working relationship between UPMC Health Plan's Network and its physicians, hospitals and other providers.