Corporate Utilization Management Medical Director

Amerihealth
Published
October 6, 2020
Location
Philadelphia, PA
Category
Job Type

Description

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

Responsibilities:

The Corporate UM Medical Director provides medical leadership to a multidisciplinary team for utilization, prior authorization, and appeals functions. Primary responsibility lies in leading the development, implementation and execution of medical policy as it relates to health services utilization.

Major accountabilities:

  • Leads a team of Medical Directors responsible for utilization management, prior authorization, behavioral health reviews and appeals.
  • Monitors performance of team to ensure appropriate resource allocation and process efficiency.
  • Provides timely medical reviews, drive clinical improvement, help educate and lead the clinical staff on matters involving utilization.
  • Provides clinical determinations based on evidence-based criteria and guidelines.
  • Provides clinical expertise and business direction in support of medical management programs
  • Monitors performance metrics across LOBs and assures that appropriate actions are taken to address performance opportunities consistent with enterprise policies.
  • Participates in RFP responses and new plan implementation
  • Assists in developing policies and processes
  • Ensures compliance with all contractual requirements

Education/Experience:

  • MD/DO degree required
  • Successful candidate will have multi-state licensure without restrictions
  • Active Board certified in a primary care specialty (Internal/Family Med) preferred
  • 8+ years experience in senior management and or Medical Director experience
  • 7 years Utilization Review and Case management experience
  • 5+ years progressively responsible managerial experience
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