Medical Director – UM Optimization

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

📋 Description

• Support the Chief Medical Officer in overseeing and coordinating medical management, quality enhancement, and credentialing activities.

• Offer medical leadership for Utilization Management, cost containment, and initiatives aimed at improving medical quality.

• Assess completed tasks, analyze data, and make informed decisions for strategic process enhancements.

• Conduct medical reviews pertaining to utilization assessments, quality assurance, and complex, contentious, or experimental medical services.

• Aid in performance improvement efforts for capitated providers.

• Contribute to the planning of objectives and policies aimed at enhancing the quality and cost-effectiveness of care.

• Provide medical insight for quality enhancement and utilization management programs.

• Assist in structuring physician committees, including processes and membership.

• Carry out regular rounds for high-risk patients and work together with care management teams.

• Collaborate with clinical teams, network providers, appeals teams, and medical and pharmacy consultants on intricate cases and medical necessity appeals.

• Engage in the development of provider networks and expansion into new markets.

• Support physician education on clinical matters and policies.

• Identify studies for utilization review, adverse utilization patterns, unusual provider practice behaviors, and issues regarding benefit/payment adequacy.

• Detect clinical quality improvement studies designed to minimize unwarranted variations in clinical practices.

• Work alongside physicians and providers to implement recommendations that enhance utilization and healthcare quality.

• Review complex, contentious, unusual, or new-service claims for medical necessity and appropriate reimbursement.

• Foster provider-community alliances through medical management initiatives.

• Represent the business unit in front of local and national audiences, state committees, and ad hoc committees as necessary.

⛳️ Requirements

• Medical Doctor or Doctor of Osteopathy.

• Active state license as an MD or DO with no restrictions, limitations, or sanctions from government programs.

• Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services.

• Certification in the Psychiatry specialty is mandatory.

• Engaged in the active practice of medicine.

• Preferred experience in Utilization Management and familiarity with quality accreditation standards.

• Strong preference for candidates with Payer/Managed Care experience.

• Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.

• Experience in treating or managing care for a culturally diverse population is preferred.

• Availability to work weekends and holidays as required may be necessary.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement program.

• Paid time off along with holidays.

• Flexible work arrangements available, including remote, hybrid, field, or office schedules.

• Additional incentives may be included in the total compensation package.

• Equal opportunity employer dedicated to promoting diversity.