Remote Medical Director, Utilization Management

GuideWell Mutual Holding Corporation; Town of Florida (NY); Remote; USD 224,000 - 364,000; Full time

Benefits offered by this job

Medical, dental, vision

Life insurance

Disability coverage

Retirement plan with company match

Paid time off & holidays

Well-being benefits

Job summary

GuideWell Mutual Holding Corporation is seeking a Medical Director to lead all utilization management reviews (Pre-service, Post-service, Concurrent Review and Appeals) and to collaborate with physician providers and Case Managers on complex cases.

The ideal candidate holds a Florida medical license (MD/DO), BS/ABMS board certification or eligibility, and 5+ years of clinical experience, with strong communication and team collaboration in a fast-paced environment.

Qualifications

• Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine.
• Board Certification or Board eligibility by American Board of Medical Specialties or equivalent.
• 5+ years of clinical experience.
• Experience working in a dynamic, fast-paced environment.
• Excellent verbal and written communication.

Responsibilities

• Perform all types of utilization management (UM) reviews, including Pre-service, Post-service, Concurrent Review and Appeals.
• Discuss cases with physician providers (Peer to Peer).
• Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests.
• Collaborate with Case Managers to provide support and guidance on cases needing physician assistance.
• Meet metrics related to UM review efficiency, timeliness, and quality of review.
• Participate in Inter-rater reliability (IRR) audits and health plan audits as necessary.
• Assist nurses and other staff in understanding utilization review principles and policy benefits.
• Participate in development/review of Medical and Pharmacy policies.
• Serve as a subject matter expert for the organization.
• Lead as Medical Director consultant for a sub-category of utilization management (e.g., commercial or Medicare medical policy).
• Perform other duties as assigned.

Skills

Clinical experience

Medical licensure

Board Certification

Communication skills

Team collaboration

Education

MD or DO degree

Job description

GuideWell Mutual Holding Corporation is seeking a Medical Director to lead all utilization management reviews (Pre-service, Post-service, Concurrent Review and Appeals) and to collaborate with physician providers and Case Managers on complex cases.

The ideal candidate holds a Florida medical license (MD/DO), BS/ABMS board certification or eligibility, and 5+ years of clinical experience, with strong communication and team collaboration in a fast-paced environment.