Medical Director – Benefit/Utilization Management

This is a fully remote position, open to applicants in Oregon.

📋 Description

• Supervise clinical and wellness initiatives that support CareOregon members.

• Collaborate with the Senior Medical Director to develop, implement, and manage clinical and wellness programs.

• Direct and oversee programs related to utilization, case management, disease management, and quality management.

• Educate participating physicians and network providers on topics such as quality management, utilization management, best clinical practices, population management, and performance metrics.

• Act as a representative of the health plan in medical, professional organizations, and community events.

• Serve as the medical spokesperson, supporting CCOs, contract negotiations, and provider expansion activities.

• Lead efforts to maintain a motivated, productive, and skilled team.

• Offer medical support for Care Management and Care Coordination activities.

• Provide oversight as a medical director for benefit determinations and appeals related to medical and pharmacy services.

• Work collaboratively with CCO/LOB Medical Directors to develop clinical strategies and interventions.

• Implement programs that address the needs of high-risk members while enhancing care and service quality.

⛳️ Requirements

• Must be a board-certified medical doctor or doctor of osteopathy in one of the primary care specialties, including obstetrics/gynecology.

• Must be a licensed physician (MD or DO) in the State of Oregon.

• At least 3 years of experience as a physician is required.

• A minimum of 4 years in a supervisory role is preferred.

• Experience in benefit/utilization management is preferred.

• Leadership experience is preferred, especially in managed care, quality assurance, utilization review, and case management.

• Knowledge of clinical management for a range of medical issues is essential.

• Basic understanding of regulatory and contractual requirements for Medicaid, Medicare, and commercial insurance is necessary.

• Familiarity with the operations of managed care is required.

• Knowledge of guideline development, outcomes management, population health improvement, disease management, cost effectiveness, and cost analysis studies is important.

• Awareness of physician/provider payment issues, physician practice models, total quality, and continuous quality improvement concepts is necessary.

• Skills related to medical policy, quality, case and disease management, credentialing, and utilization management are required.

• Ability to see, read, and perform repetitive finger and wrist movements for at least 6 hours/day is needed.

• Ability to hear and speak clearly for at least 3–6 hours/day is required.

🏝️ Benefits

• 0.8 position with benefits.

• Bonus opportunity; Bonus - SIP Target, 10% Annual.

• Medical, dental, vision, life, AD&D, and disability insurance.

• Health savings account.

• Flexible spending account(s).

• Lifestyle spending account.

• Employee assistance program.

• Wellness program.

• Discounts.

• Supplemental benefits including voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, and 529 College Savings.

• Retirement plan with employer contributions.

• PTO.

• Paid State Sick Time.

• Paid holidays.

• Volunteer time.

• Jury duty leave.

• Bereavement leave.

• 401(k) contributions for non-benefits eligible employees.

• Work from home.