Medical Director – Benefit/Utilization Management

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

📋 Description

• Manage clinical and wellness programs and initiatives to support CareOregon members

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

• Lead and supervise utilization, case, disease, and quality management programs

• Create and execute physician education initiatives related to quality and utilization management

• Act on behalf of the health plan in medical and professional organizations

• Improve CareOregon’s reputation within the community

• Serve as the medical spokesperson for Coordinated Care Organizations, contract negotiations, and provider expansion efforts

• Provide leadership through open communication and effective delegation of responsibilities and authority

• Offer medical support for Care Management and Care Coordination activities

• Oversee medical director functions, including benefit determinations and medical and pharmacy appeals

• Partner with CCO/Line of Business Medical Directors on clinical strategies and interventions

• Educate network providers on optimal clinical practices utilizing population/panel management and performance data

• Work remotely using standard office equipment and may require travel outside of the workplace

⛳️ Requirements

• Board-certified medical doctor or doctor of osteopathy in one of the primary care specialties, including obstetrics/gynecology

• Licensed physician (MD or DO) in the State of Oregon

• At least 3 years of experience as a physician

• Preferably 4 years of supervisory experience

• Experience in benefit/utilization management is preferred

• Leadership experience, ideally in managed care, quality assurance, utilization review, and case management

• Strong clinical knowledge regarding the management of a variety of medical conditions

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

• Familiarity with managed care operations

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

• Understanding of physician/provider payment issues, physician practice models, total quality, and continuous quality improvement concepts

• Proficiency in medical policy relating to quality, case and disease management, credentialing activities, and utilization management

• Exceptional communication and collaboration skills

• Capability to implement clinical and wellness programs targeted at high-risk members

• Ability to work efficiently in cross-functional teams and with diverse individuals and groups

• Competence in planning, setting priorities, effectively delegating, and managing time

• Skills in quality management techniques within a large, structured managed care environment

• Commitment to enhancing access and quality of care for underserved and uninsured populations

• Ability to see, read, and perform repetitive finger and wrist movements for a minimum of 6 hours per day

• Capability to hear and speak clearly for 3 to 6 hours per day

🏝️ Benefits

• 0.8 position that includes benefits

• Bonus potential; Bonus - SIP Target, 10% Annual

• Comprehensive medical, dental, and vision insurance

• Life, AD&D, and disability insurance

• Health savings account

• Flexible spending account(s)

• Lifestyle spending account

• Employee assistance program

• Wellness program

• Discount opportunities

• 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

• Paid time off (PTO)

• Paid state sick time

• Paid holidays

• Volunteer time

• Jury duty leave

• Bereavement leave

• 401(k) contributions

• Occasional travel may be necessary or optional