Medical Director, Utilization Management

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

📋 Description

• Provide clinical oversight and guidance to ensure the quality and effectiveness of healthcare services.

• Develop and execute clinical protocols, guidelines, and standards.

• Monitor and assess clinical performance metrics and outcomes.

• Lead initiatives aimed at improving quality to enhance patient care and safety.

• Oversee the implementation of evidence-based practices and clinical pathways.

• Analyze clinical data to identify opportunities for improvement.

• Collaborate with Quality, Care Management, and Population Health teams to enhance HEDIS, Stars, preventive care, care gap closure, and utilization performance metrics.

• Assist in identifying and managing high-risk, high-cost, and high-opportunity patient populations through data-driven interventions.

• Build relationships with network physicians and healthcare providers.

• Address clinical concerns, enhance care coordination, and promote best practices among providers.

• Facilitate education and training programs for providers.

• Offer physician leadership for utilization management activities.

• Engage in prospective, concurrent, and retrospective utilization reviews, including assessments of medical necessity, treatment plans, hospital admissions, and specialty referrals.

• Act as a clinical resource for complex cases involving utilization, authorization, and care management.

• Develop, implement, and refine policies, procedures, clinical criteria, and authorization guidelines related to utilization management.

• Analyze utilization trends, referral patterns, inpatient and outpatient data, and opportunities for care coordination.

• Participate in appeals and peer discussions with health plans and providers.

• Provide clinical oversight concerning high-risk patient management, transitions of care, and complex case reviews.

• Participate in or chair Utilization Management Committee meetings.

• Present utilization trends, performance metrics, and areas for improvement to leadership.

• Ensure adherence to regulatory requirements and industry standards.

• Manage audit processes and accreditation activities.

• Contribute to the IPA's strategic planning and identify growth opportunities.

• Engage in network expansion, provider recruitment, retention, interviews, onboarding, and orientation.

• Serve as an AMG Friendly Physician for the Southern California Region.

⛳️ Requirements

• MD or DO degree from an accredited medical institution.

• Active and unrestricted medical license.

• At least 5 years of clinical experience, including a minimum of 3 years in a leadership position.

• Board certification in a recognized medical specialty.

• Strong knowledge of quality improvement methodologies and healthcare regulations.

• Exceptional communication, leadership, and interpersonal abilities.

• Capability to analyze complex clinical data and generate actionable insights.

• Comprehensive understanding of utilization management, care management, population health, and value-based care principles.

• Proficient in conducting medical necessity reviews and assessing clinical appropriateness based on evidence-based guidelines.

• Experience in managing provider appeals, authorization reviews, and interactions with payers.

• Familiarity with HEDIS, Stars, RAF, quality incentive programs, and managed care performance metrics.

• Proven ability to influence physician behavior through education, collaboration, and data-driven performance improvements.

• Experience in an IPA, health plan, ACO, delegated medical group, managed care, or value-based care environment is highly preferred.

• Prior experience as a Medical Director, Associate Medical Director, or Physician Advisor supporting utilization management, care management, population health, or quality programs is preferred.

• Experience working with delegated managed care arrangements, health plan partners, and utilization management committees is preferred.

• External candidates must successfully pass a background check and drug screening.

🏝️ Benefits

• Comprehensive medical, vision, and dental coverage.

• 401k savings plan with employer matching.

• Flexible time off policy.

• 9 Paid Holidays.

• Eligibility to participate in the annual bonus program.