Medical Director, Utilization Management

Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) degree. Board Certified Family Practitioner or Internal Medical Specialist preferred. Unrestricted licensed in at least one state within the United States. 5+ years of clinical practice experience. 2+ years of experience in utilization management activities. Proficiency with Microsoft Office applications. M.D or D.O and five (5) years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry. Board Certified in an American Board of Medical Specialties Board. Active, unrestricted license to practice medicine in a state or territory of the United States. Previous experience with administrative oversight of the medical function of an insurance (or related) company. Previous experience leading a team of professionals. Strong perspective on increasing operational excellence and automation. Strong interpersonal skills. Ability to balance critical thinking with hands-on execution. Forward-thinking strategic leader. Results-driven. Ability to work in a fast-paced and changing environment. Self-starter with strong organizational skills. Excellent oral and written communication skills.

Provide medical expertise and decision making within the Utilization Management team. Ensure healthcare services are medically necessary, appropriately utilized, and meet quality standards. Adhere to Federal, State and CMS compliant medical policies. Review clinical cases and provide medical expertise. Collaborate with stakeholders for efficient healthcare delivery. Conduct post service reviews for medical necessity and benefits determination coding. Perform secondary review for cases not meeting medical necessity criteria. Participate in Grievance and Appeal review process. Identify process improvement opportunities and inefficiencies. Collaborate with management and operations for strategic solutions.