Medical Director – Managed Care Plans

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

📋 Description

• Influence the future of healthcare delivery within one of the leading academic health systems in the nation.

• Direct clinical strategy and utilization management for our integrated health plans and care management initiatives.

• Conduct utilization reviews for service requests, including but not limited to inpatient, outpatient, pharmacy, and dental services.

• Engage in peer-to-peer discussions with healthcare providers.

• Participate in and support the operations of committees such as the Utilization Management Committee and the Pharmacy & Therapeutics Committee.

• Provide guidance to the HealthCare Senior Management team on the use of healthcare services and interventions to enhance the delivery of medically necessary services.

• Participate in and/or lead rounds in areas such as disease management, care management, or admissions.

• Assist with Plan accreditation processes (NCQA) and support Utilization, Quality, and Disease Management programs.

• Create and update practice guidelines for both acute and chronic care.

• Develop and enforce policies and procedures aimed at promoting effective utilization management and achieving set targets.

• Collaborate with HealthCare Economics and Finance to enhance data collection and utilization outcomes.

• Represent HealthCare Management internally and externally as directed by the VP Chief Medical Officer.

• Formulate and execute work plans to maximize appropriate utilization and quality targets as instructed by the VP Chief Medical Officer.

• Carry out additional job responsibilities as assigned.

⛳️ Requirements

• A Medical Physician (MD or DO) is required.

• A Pennsylvania Medical License without restrictions is necessary.

• Board Certification in a specialty is required (primary care preferred).

• A graduate business degree is advantageous (MBA, MMM, etc.).

• A minimum of 5 years of post-residency experience in the clinical practice of medicine is required.

• Experience in managed care with responsibility for utilization management is essential.

• Excellent organizational, interpersonal, time management, and communication skills are required.

• Strong leadership abilities are essential.

• Proficiency in conflict resolution and independent decision-making is necessary.

• Exceptional project management skills are required.

• Strong influencing, negotiation, and analytical skills are needed.

• Familiarity with PC-based applications, such as Excel, Access, and Word, is required.

• Knowledge of the principles of Utilization, Quality, and Care Management is essential.

🏝️ Benefits

• Medical (including prescription) insurance.

• Supplemental insurance.

• Dental insurance.

• Vision insurance.

• Life and AD&D insurance.

• Short- and long-term disability coverage.

• Flexible spending accounts.

• Retirement plans.

• Tuition assistance.

• Access to group rates on insurance and various discounts.

• Tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service.

• Access to medical (including prescription) insurance for all colleagues, including those working less than part-time.