In this role, you will lead the operational areas of the Utilization Management (UM) program including prospective, concurrent, and retrospective reviews. As a Medical Director, UM you ensure all patient care decisions and referrals are medically appropriate by using national and local criteria. Our Medical Directors, UM help develop and implement medical policies, procedures, and clinical guidelines aligned with contractual obligations and regulatory guidelines. They partner with Quality Improvement teams to analyze utilization trends and develop interventions to improve clinical effectiveness. Medical Directors, UM also serve as a key point of contact for physicians and providers, conducting peer-to-peer discussions to facilitate collaborative care and resolve issues. In addition, you will collaborate with Corporate Medical Directors, our Utilization and Case Management RNs and staff, and the Vice President, Medical Affairs.
Work Arrangement
Responsibilities
Education and Experience
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Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) required
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Master of Health Administration (MHA), Master of Public Health (MPH), or Master of Business Administration (MBA) in Healthcare Management preferred
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A minimum of three years of utilization management or appeals experience in a Medicaid, Medicare, and/or dual eligible
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A minimum of five years of clinical practice experience required in family medicine, pediatrics, internal medicine, surgery, neonatology, or physiatry
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Proficiency utilizing MS Office Suite, internet applications, and electronic medical record and documentation programs
Licensure
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.
For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
Your career starts now. We are looking for the next generation of health care 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.
