Medical Director – Health Plan
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Job Description
Medical Director leading medical policy and utilization management for a technology-enabled health plan. Collaborating with teams to enhance member care delivery and management.
Responsibilities:
- Lead utilization management strategy, including oversight of medical necessity determinations and review processes
- Own medical policy development, incorporating regulatory updates and care guideline changes
- Lead and Partner with the Utilization Management Review Committee
- Provide medical oversight, expertise, and leadership to ensure the delivery of cost effective, quality healthcare services to health plan members
- Promote positive relations with the local medical community, including periodic consultation with providers, facilities, caregivers, etc.
- Review case management data to identify trends, gaps in care, and recommend corrective actions
- Provide oversight and direction for staff and provider training and education
- Integrate clinical quality and best clinical practices into medical management program development
- Evaluate the development of new programs and the continuation of existing programs
- Investigate future care management and patient engagement technologies and evaluate their impact on providers’ practices, patient safety, and patient experience
Requirements:
- Active, unrestricted Texas (TX) medical license without limitations or sanctions
- Doctor of Medicine (MD) with 8+ years of clinical experience; management experience preferred
- Board certification in a specialty recognized by the American Board of Medical Specialties
- Experience working within a health insurance plan, with an emphasis on population health
- Experience in managed care and utilization management, including performing utilization reviews within a health plan
- Strong knowledge of managed care systems, quality improvement, and clinical best practices
- Experience with MCG or other clinical guidelines
Benefits:
- Competitive salary
- Comprehensive health, dental, and vision insurance as well as life and disability
- Retirement savings plan with company match
- Generous time off/vacation
- Professional development opportunities
- Flexible and remote work environment
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