Medical Director, Utilization Management - Remote

Overview

The Medical Director of Utilization Management is responsible for providing medical expertise and decision making within the Utilization Management team, ensuring that healthcare services are medically necessary and appropriately utilized.

In Short

• Lead development and maintenance of an efficient Utilization Management program.
• Educate primary care physicians on regulatory compliance.
• Develop strategies for market performance improvement.
• Participate in case reviews and medical necessity determination.
• Serve as a resource for clinical staff on complex cases.
• Conduct post service reviews for medical necessity.
• Maintain thorough documentation of activities and decisions.
• Analyze aggregate data and reports for physicians.
• Act as a liaison between physicians and health plan Medical Directors.
• Participate in Grievance and Appeal review processes.

Requirements

• Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) degree.
• Board Certified Family Practitioner or Internal Medical Specialist preferred.
• Unrestricted license in at least one U.S. state.
• 5+ years of clinical practice experience.
• 2+ years in utilization management activities.
• Proficiency with Microsoft Office applications.
• Experience in Health Care Delivery System.
• Previous administrative oversight experience in insurance.
• Experience leading a team of professionals.
• Strong organizational and communication skills.

Benefits

• Opportunity to lead and shape healthcare delivery.
• Collaborative and supportive work environment.
• Engagement with various stakeholders in healthcare.
• Involvement in special projects and training opportunities.
• Focus on process improvement and technology partnerships.