Medical Director Utilization Management Appeals

In this role, you will lead the operational areas of the Utilization Management (UM) program including prospective, concurrent, and retrospective reviews. As a Medical Director, UM you ensure all patient care decisions and referrals are medically appropriate by using national and local criteria. Our Medical Directors, UM help develop and implement medical policies, procedures, and clinical guidelines aligned with contractual obligations and regulatory guidelines. They partner with Quality Improvement teams to analyze utilization trends and develop interventions to improve clinical effectiveness. Medical Directors, UM also serve as a key point of contact for physicians and providers, conducting peer-to-peer discussions to facilitate collaborative care and resolve issues. In addition, you will collaborate with Corporate Medical Directors, our Utilization and Case Management RNs and staff, and the Vice President, Medical Affairs.

Work Arrangement

• Remote role

• Monday through Friday from 8:30a EST to 5:00p EST

• Weekend call once per quarter and evening call once per quarter and a holiday rotation.

Responsibilities

• Ensures quality and clinically sound services for all enrollees through associates and providers.

• Serves as medical advisor and manager for all clinically related activities

• Ensures that the organization's medical policies and procedures adhere to contractual obligations

• Performs clinical case reviews in conjunction with the Medical Excellence Department.

• Demonstrates knowledge of prescribed and established medical procedures and practices

• Maintains familiarity with federal, state, and local medical and clinical operations regulations. Provides leadership in developing and implementing medical policy related to health management, compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations

• Manages day-to-day operations and monitors the integration and processing of members to optimize the appropriate use of behavioral and physical health services.

• Participates with Quality Improvement and Medical Excellence in identifying and analyzing medical and behavioral health information to develop interventions to improve the clinical effectiveness of medical management strategies. Work closely with a multidisciplinary team to ensure behavioral health management and quality management programs meet contractual obligations

• Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff

• Trains staff on medical issues and provides consultation to staff as appropriate

• Assists Care Managers in assessing members' needs for case management services and attends meetings and monthly rounds as scheduled

• Collaborates with the integrated case management team during scheduled meetings and informally as needed

• Thoroughly documents all care coordination activity in the member's medical record in the electronic case management documentation system

Education and Experience

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) required

• Master of Health Administration (MHA), Master of Public Health (MPH), or Master of Business Administration (MBA) in Healthcare Management preferred

• A minimum of three years of utilization management or appeals experience in a Medicaid, Medicare, and/or dual eligible

• A minimum of five years of clinical practice experience required in family medicine, pediatrics, internal medicine, surgery, neonatology, or physiatry

• Proficiency utilizing MS Office Suite, internet applications, and electronic medical record and documentation programs

Licensure

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) with a Pennsylvania medical license that is active and in good standing.

• Additional medical licensure is required in all states where AmeriHealth Caritas has a line of business. The application is expected to be initiated within 30 days of hire.

• Must be board certified Family Medicine or Med/Peds. Must be clear of any sanctions by the applicable state or the Office of the Inspector General.

• Must not be prohibited from participating in any Federally or state-funded healthcare programs.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

Your career starts now. We are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.

Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at

As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.