Medical Management Director

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

📋 Description

• Design and execute strategic initiatives for care management, utilization management, and appeals programs.

• Lead and guide a team of professionals within these domains.

• Collaborate with senior leadership to synchronize departmental objectives with the organization's mission and goals.

• Oversee program budgets and the care model under the supervision of the Chief Medical Officer (CMO).

• Supervise the creation and implementation of care management programs aimed at improving member outcomes and satisfaction while reducing overall care costs.

• Ensure that Care Management is incorporated into the overarching population health strategy.

• Monitor and assess care management performance metrics, implementing strategies for improvement.

• Manage the utilization review processes to guarantee appropriate resource utilization and compliance with clinical guidelines.

• Formulate utilization management policies and procedures that adhere to regulatory standards and payer requirements.

• Analyze utilization data to pinpoint trends and opportunities for cost savings and quality enhancement.

• Oversee the appeals processes to ensure the prompt and accurate handling of denials and appeals.

• Develop and sustain appeals management policies and procedures that comply with regulatory and contractual obligations.

• Collaborate with clinical and operational teams to address complex cases and enhance the appeals process.

• Manage contracts with appeals vendors.

• Ensure that programs comply with federal, state, and local regulations as well as accreditation standards.

• Implement initiatives aimed at quality improvement.

• Stay updated on industry trends and best practices.

• Work alongside internal and external stakeholders, including healthcare providers, payers, and regulatory agencies, to optimize care delivery and resource utilization.

• Promote communication and collaboration among multidisciplinary teams.

⛳️ Requirements

• Bachelor's Degree in a related health field is preferred.

• At least 2-3 years of experience in Health Plan Medical Management (Utilization Management and Appeals).

• Demonstrated leadership experience.

• Working knowledge of human resource principles.

• Compliance with applicable regulatory requirements.

• Ability to be adaptable and agile in effectively addressing complex, multifaceted, and/or emotionally charged situations.

• Advanced proficiency in Microsoft Products.

• Capacity to adapt to electronic documentation systems.

• Exceptional communication, writing, analytical, and problem-solving skills.

🏝️ Benefits

• Competitive cash compensation.

• Comprehensive health plans.

• Generous paid time off (PTO).

• Future-focused 401k matching.

• Flexible schedules to accommodate the diverse needs of our employees.

• Opportunities for professional development and training.

• Social and recreational programs.