Medical Director, Utilization Management

Stellenbeschreibung:

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
Lead quality improvement initiatives to enhance patient care and safety
Oversee evidence-based practices and clinical pathways
Review 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
Foster relationships with network physicians and healthcare providers
Address clinical issues, improve care coordination, and promote best practices with providers
Facilitate provider education and training programs
Provide physician leadership for utilization management activities
Participate in prospective, concurrent, and retrospective utilization reviews, including medical necessity determinations, treatment plans, hospital admissions, and specialty referrals
Serve as a clinical resource for complex utilization, authorization, and care management cases
Develop, implement, and refine utilization management policies, procedures, clinical criteria, and authorization guidelines
Analyze utilization trends, referral patterns, inpatient and outpatient utilization data, and care coordination opportunities
Participate in appeals and peer-to-peer discussions with health plans and providers
Provide clinical oversight related to high-risk patient management, transitions of care, and complex case reviews
Participate in and/or chair Utilization Management Committee meetings
Present utilization trends, performance metrics, and improvement opportunities to leadership
Ensure compliance with regulatory requirements and industry standards
Manage audits and accreditation processes
Contribute to the IPA's strategic plan and identify growth opportunities
Participate in network expansion, provider recruitment, retention, interviews, onboarding, and orientation
Serve as AMG Friendly Physician for the Southern California Region

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 a leadership role
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
Experience in an IPA, health plan, ACO, delegated medical group, managed care, or value-based care environment strongly preferred
Prior experience serving as a Medical Director, Associate Medical Director, or Physician Advisor supporting utilization management, care management, population health, or quality programs preferred
Experience working with delegated managed care arrangements, health plan partners, and utilization management committees preferred
External hires must pass a background check/drug screen

Core Competencies

Demonstrates expertise in clinical oversight, utilization management, and quality improvement within healthcare settings. Proficient in analyzing clinical data, developing protocols, and fostering provider relationships to enhance patient care and safety.