Utilization Management, Medical Director

The Utilization Management, Medical Director is a key physician responsible for advancing clinical excellence, quality outcomes, and utilization management across the network. This is an individual contributor role, primarily performing utilization management functions.

Responsibilities

Provide clinical oversight and direction to ensure the quality and efficiency of healthcare services; Develop and implement clinical protocols, guidelines, and standards; Monitor and evaluate clinical performance metrics and outcomes; Oversee the implementation of evidence-based practices and clinical pathways; Conduct regular reviews of clinical data to identify areas for improvement; Partner with Quality, Care Management, and Population Health teams to improve HEDIS, Stars, preventive care, care gap closure, and utilization performance metrics; Support identification and management of high-risk, high-cost, and high-opportunity patient populations through data-driven interventions; Collaborate with providers to address clinical issues, improve care coordination, and promote best practices; Participate in peer-to-peer discussions; Management of utilization management queues and individual member cases in the areas of prior authorization, inpatient concurrent review, readmission reviews, network adequacy, claim reviews, appeals, pharmacy reviews, and peer-to-peer communication; Collaborate with care management, case management, and network providers to support high-quality, cost-effective patient care; Serve as a clinical resource for complex utilization, authorization, and care management cases; Support development, implementation, and refinement of utilization management policies, procedures, clinical criteria, and authorization guidelines; Analyze utilization trends, referral patterns, and opportunities for improved care coordination and resource stewardship; Partner with operational and clinical leaders to achieve utilization, quality, and population health performance goals; Participate in appeals and peer-to-peer discussions with health plans and providers regarding medical necessity and coverage determinations; Provide clinical oversight and input related to high-risk patient management, transitions of care, and complex case reviews; Support provider education regarding utilization management principles, evidence-based practice standards, and appropriate resource utilization; Participate in and/or chair Utilization Management Committee meetings as assigned; Present utilization trends, performance metrics, and improvement opportunities to clinical and operational leadership; Ensure compliance with regulatory requirements and industry standards; Manage audits and accreditation processes; Contribute to the development and execution of the IPA's strategic plan; Identify opportunities for growth and expansion of services; Collaborate with executive leadership to align clinical goals with organizational objectives; Participate in network expansion efforts through presentations and outreach to strategic provider prospects

Requirements

MD or DO degree from an accredited medical school; Active and unrestricted medical license; Minimum of 5 years of clinical experience, with at least 3 years in utilization management; Board certification in a medical specialty; Strong understanding of quality improvement methodologies and healthcare regulations; Excellent communication, leadership, and interpersonal skills; Ability to analyze complex clinical data and develop actionable insights; Strong knowledge of utilization management, care management, population health, and value-based care principles; Ability to conduct medical necessity reviews and evaluate clinical appropriateness using evidence-based guidelines; Experience managing provider appeals, authorization reviews, and payer interactions; Understanding of HEDIS, Stars, RAF, quality incentive programs, and managed care performance metrics; Demonstrated ability to influence physician behavior through education, collaboration, and data-driven performance improvement

Nice to have

Experience in an IPA, health plan, ACO, delegated medical group, managed care, or value-based care environment; Experience with utilization management, medical necessity review, provider appeals, care management, population health, and quality improvement programs; Prior experience serving as a Medical Director, Associate Medical Director, or Physician Advisor supporting utilization management, care management, population health, or quality programs; Experience working with delegated managed care arrangements, health plan partners, and utilization management committees

Benefits

Excellent medical, vision, and dental coverage; 401k savings plan with a company match; Flexible time off; 9 Paid Holidays