Utilization Management Medical Director - Remote Eligible

Medical Director, Utilization Management

The Medical Director, Utilization Management, provides organizational leadership in the operational areas of appeals, utilization review, quality improvement, and related policy and practice initiatives in collaboration with the Corporate Medical Directors, Utilization Management and the Vice President, Medical Affairs.

Remote role.

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

Weekend call once per quarter and evening call once per quarter.

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.

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.

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 (3) years of utilization management or appeal experience in a Medicaid, Medicare, dual eligible, or commercial health plan preferred.

A minimum of five (5) years of clinical practice experience required.

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

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 in Family Medicine, Internal Medicine, or General Pediatrics. 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.

Your career starts now. We are looking for the next generation of healthcare 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 www.amerihealthcaritas.com.

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.