[Hiring] Medical Director, Utilization Management @UPMC

Role Description

The UPMC Health Plan is seeking a Medical Director to join our Utilization Management team. The ideal candidate will have a minimum of 10 years of clinical experience, as well as experience working with a Health Plan.

The Medical Director, Utilization Management is responsible for assuring physician commitment and delivery of comprehensive high-quality health care to UPMC Health Plan members. This fully remote role will be responsible for:

• Assuring physician commitment and delivery of comprehensive high-quality health care to UPMC Health Plan members.
• Overseeing adherence to quality and utilization standards through committee delegations.
• Establishing effective working relationships between UPMC Health Plan's Network and its physicians, hospitals, and other providers.

Responsibilities

• Provide leadership direction for provider credentialing processes.
• Ensure physicians devote sufficient time to the CHC-MCO for timely medical decisions, including after-hours consultation as needed.
• Lead and direct efforts in meeting Quality Improvement and Care Management goals aimed at improving member health status outcomes and established business strategies.
• Provide expedited review and determination of medically pressing issues in accordance with established policies of the Health Plan.
• Participate in daily utilization management and quality improvement review processes, including concurrent, prospective, and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns.
• Stay current with accepted standards and professional developments in quality improvement and utilization management.
• Communicate and educate network providers regarding clinical guidelines, pathways, protocols, and standards related to quality and utilization processes.
• Report the communication of reportable communicable diseases in accordance with statute.
• Interact with physicians regarding opportunities to improve member satisfaction and compliance with Utilization Management and Quality Improvement policies and procedures.
• Work with the DOH State and District Office Epidemiologists in partnership with designated county/municipal health department staff to report reportable conditions in accordance with 28 Pa. Code 27.1 et seq.
• Support implementation of the Health Plan's Quality Improvement and Care Management Programs through daily interventions.
• Represent the Health Plan in external accreditation and certification activities.
• Act as the first level physician reviewer for all cases referred by the Quality Improvement and Care Management Departments.
• Support adherence to quality and utilization standards and establish effective working relationships between UPMC Health Plan's Network and its physicians, hospitals, and other providers.

Qualifications

• Doctor of Medicine or Doctor of Osteopathy from an accredited school (Required).
• Minimum of 5-10 years of clinical experience (ideal candidates).
• Managed Care experience preferred.
• Preference for candidates with board certification in Internal Medicine, Family Medicine, Geriatric Medicine, or Emergency Medicine.

Requirements

• Doctor of Medicine (MD) OR Doctor of Osteopathic Medicine (DO).
• PA Medical License.

Benefits

• Premier benefits package designed to care for your total well-being — physically, emotionally, and financially.
• Endless opportunities for career advancement and growth.

Company Description

UPMC is an Equal Opportunity Employer/Disability/Veteran.