Medical Director

Medical Director – Utilization Management

As part of a physician team, the Medical Director ensures utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of requested treatments or services. Depending on the nature of the case, telephonic peer-to-peer discussions may be required. The Medical Director ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of a multidisciplinary team for case and disease management and advises the team on high-risk and complex cases. Special projects may also be assigned to support and improve member care.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer-to-peer discussions, to determine medical necessity and appropriateness.
• Complete initial determinations, appeals, grievances, and other reviews as assigned.
• Compose clear and concise rationales for provider and member determination notifications while adhering to required compliance standards including NCQA, URAC, CMS, DOH, and DOL regulations.
• Ensure all aspects of the medical management process are consistent with community standards of care.
• Participate as a member of the CMDM multidisciplinary team.
• Attend huddles and grand rounds.
• Advise multidisciplinary teams on cases requiring physician expertise.
• Participate in protocol and guideline development to ensure consistency in the review process.
• Manage projects and/or participate on project teams requiring physician subject matter expertise.
• Preference will be given to candidates with payer-side Utilization Management experience within a health insurance environment. Candidates with only hospital-side UM experience may not meet requirements.

Required Qualifications

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO).
• Minimum 5 years of direct patient care experience in hospital, outpatient, or private practice settings.
• Board Certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards.
• Active medical state licensure required for PA, NY, or WV.
• Expected productivity: 55+ cases completed in an 8-hour day.
• Critical thinking skills.
• Case management experience.
• Customer service skills.
• Strong oral and written communication skills.
• Collaboration and listening skills.
• Telephone skills.
• General computer skills.
• Experience with clinical software.
• Managed care experience.

Preferred Qualifications

• Master's Degree in Business Administration/Management or Public Health.
• Minimum 1 year of Medical Management experience within a Health Insurance Plan.
• Strong knowledge of the managed care industry.
• Experience with MCG or InterQual.