Medical Director - Medicare/Medicaid - Utilization Management

We are seeking an experienced and highly qualified Medical Director to join our team and lead our Utilization Management department. The Medical Director will be responsible for case/utilization management reviews, overseeing the utilization management process, and ensuring the efficient and effective use of healthcare resources while maintaining high standards of care. The successful candidate will play a crucial role in enhancing healthcare services and improving patient outcomes.

Annual Salary: $175,000

Key Responsibilities:

Strategic Leadership:

• Provide strategic direction and leadership for the Utilization Management department.
• Develop and implement utilization management strategies to optimize resource allocation.

Utilization Review:

• Oversee the utilization review process, including denials/appeals, pre-authorization, concurrent review, and retrospective review.
• Ensure compliance with regulatory requirements and industry standards

Quality Improvement:

• Collaborate with quality improvement teams to enhance the quality of healthcare services.
• Identify areas for improvement and implement quality improvement initiatives.

Clinical Oversight:

• Review and approve clinical guidelines and protocols for utilization management.
• Provide clinical expertise and guidance to the utilization management team and physicians.

Client Collaboration:

• Collaborate with healthcare entities to foster effective communication and cooperation.
• Address clinical concerns and provide recommendations for improving care delivery.

Data Analysis:

Analyze utilization data and trends to identify opportunities for cost containment and improved outcomes.

• Develop data-driven recommendations for decision-making.

Requirements

Qualifications:

• Medical Doctor (M.D.) or Doctor of Osteopathic Medicine (D.O.) degree.
• Medicaid/Medicare Part D Experience
• Current, unrestricted medical license in the state of practice.
• Ability to obtain a license in MN or other states, as requested.
• Board certification in a relevant specialty.
• Highly preferred - Previous experience in utilization management and healthcare administration.
• Strong knowledge of healthcare regulations and accreditation standards.
• Excellent leadership and communication skills.
• Strong analytical and problem-solving abilities.