[Hiring] Per Diem Medical Director Utilization Management @Amerihealth Caritas

Role Description

Reporting to the Senior Medical Director of UM, the Per Diem UM Medical Director will be responsible for:

• Performing daily medical reviews, appeals, participating in appeal panel as appropriate, correspondence regarding review determinations and physician peer review activities.
• Identifying and implementing evidence-based practice guidelines throughout the provider network.
• Overseeing the quality of clinical care for network and non-network providers.
• Utilizing evidence-based standards in making coverage determinations.
• Management policies; meeting health plan inter-rater reliability guidelines.

Work Arrangement:

• Fully Remote

Hours:

• Minimum of 10 hours a week and not to exceed 20 hours a week.
• Evening, weekend and holiday coverage required.

Accountabilities

• Ensures the provision of quality and clinically sound services to all Enrollees by associates and Providers.
• Serves as medical advisor and manager for all clinically related activities.
• Assures that organization medical policies and procedures adhere to contractual obligations.
• Performs clinical case reviews in conjunction with Medical Excellence Department.
• Demonstrates knowledge of prescribed and established medical procedures and practices.
• Maintains familiarity with federal, state and local regulations that may pertain to the medical and clinical operations.
• Maintains compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations.
• Manages day-to-day operations and monitors the integration and processing of members to optimize appropriate use of behavioral and physical health services.
• Participates with Quality Improvement and Medical Excellence in the identification and analysis of medical and behavioral health information to develop interventions to improve clinical effectiveness of medical management strategies.
• Works closely with a multidisciplinary team to ensure behavioral health management and quality management programs are meeting contractual obligations.
• Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff.
• Attends case management meetings and monthly rounds as scheduled.
• Collaborates with the integrated case management team, during scheduled meetings and informally as needed.
• Thoroughly documents all care coordination activity in the member medical record in the electronic case management documentation system.
• Adheres to AmeriHealth Family of Companies (ACFC) policies and procedures and supports and carries out the ACFC mission and values.
• Other duties as assigned.

Qualifications

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine licensed to practice as a medical director; additional state licensure required in all states where ACFC has a line of business, and that application is expected within 120 days of hire.
• Must be Board-certified in a specialty with a current and unrestricted license.
• Must be clear of any sanctions by the applicable state or Office of the Inspector General.
• Must not be prohibited from participating in any Federally or State funded healthcare programs.
• 1 to 3 years of Health Plan experience.

Other Skills

• Strong written and oral communication skills-required.
• Demonstrated competency in use of healthcare data.
• Demonstrated excellent interpersonal communication skills and presentation skills.
• Experienced in conflict resolution and negotiation.
• Understanding of and expertise in quality improvement and medical economics.
• Strong leadership skills.
• Excellent analytical and problem-solving skills.
• Demonstrated ability to access department’s work quality and develop/implement process improvements to achieve regulatory and oversight compliance.
• Maintain current knowledge of and applies all applicable licensing, regulatory and industry standards.

Benefits

• Flexible work solutions including remote options, hybrid work schedules.
• Competitive pay.
• Paid time off including holidays and volunteer events.
• Health insurance coverage for you and your dependents on Day 1.
• 401(k).
• Tuition reimbursement and more.

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.