Remote Medical Director, Utilization & Quality Improvement

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

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.