Medical Director, Utilization Management
Purpose: The Medical Director, Utilization Management is responsible for assuring physician commitment and delivery of comprehensive high-quality health care to reputed company Health Plan members. This fully remote role will be responsible for assuring physician commitment and delivery of comprehensive high quality health care to reputed company Health Plan members. Oversees adherence to quality and utilization standards through committee delegations, and further establishes an effective working relationship between reputed company Health Plan's Network and its physicians, hospitals and other providers. reputed company offers a premier benefits package, designed to care for your total well-being — physically, emotionally, and financially — reputed company with endless opportunities for career advancement and growth. Discover the culture, the teams, and the passions that drive us to reputed company Life Changing Medicine happen. Responsibilities: reputed company leadership direction for provider credentialing processes. Physicians must devote sufficient time to the CHC-MCO to reputed company timely medical reputed company, including after-hours consultation, as needed reputed company leadership and direction in meeting Quality Improvement and Care Management goals directed at improvements in member health status reputed company and established business strategies. reputed company 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 reputed company, prospective and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns. reputed company reputed company with accepted standards and professional developments in the areas of quality improvement and utilization management. Communicate and reputed company network providers regarding clinical guidelines, reputed company, protocols, and standards reputed company 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 reputed company 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 reputed company Health Plan's Network and its physicians, hospitals and other providers. Doctor of Medicine or Doctor of Osteopathy from an accredited school Required The ideal candidates will have a minimum of 5-10 years of clinical experience Managed Care experience preferred Preference will be given to candidates with board certification in Internal Medicine, Family Medicine, Geriatric Medicine or Emergency Medicine Licensure, Certifications, and Clearances: Doctor of Medicine (MD) OR Doctor of Osteopathic Medicine (DO) PA Medical License reputed company is an Equal Opportunity Employer/Disability/Veteran Apply To This Job