Sr Medical Dir UM

The following responsibilities are regarding enrollees with medical conditions and their providers:

• Overseeing the quality of clinical care for network and non-network providers

• Assuring a high-performing Medical Management system that adheres to the terms of contracts and all relevant regulatory requirements

• Utilizing evidence-based standards in making coverage determinations.

Work Arraignments: Remote and must be willing to work on call rotational evening and weekend shift.

Accountabilities:

• Ensures the provision of quality and clinically sound services to all Enrollees by associates and Providers

• Leads a team of Medical Directors responsible for utilization management, prior authorization, behavioral health reviews, and appeals

• 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

• Provides leadership in the development and implementation of medical policy as it relates to health management

• 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

• Trains staff on medical issues and provides consultation to staff as appropriate

• Assists IHCM Managers in assessing members’ need for case management services

• 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

• Leads at least 2 High Value Opportunities (cost management) initiatives per year

• Leads all efforts to train/retrain current and new hires with regards to critical decision making for utilization management, appeals, and pharmacy management

• Leads all efforts in continuous quality improvement for clinical team, including ongoing audits of utilization management, peer-to-peer, quality of care reviews, appeals, and delegates oversight

• Acts as a subject matter expert in areas relevant to the medical director and pharmacy teams

• Contributes to the operations of the medical director team for functions such as scheduling

Education:

• MDlicensed to practice in the state as a medical director.

• Must be willing to obtain additional state licenses

• Must be Board-certified in their medical specialty.

• 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

Experience:

• A minimum of 3 to 5 years State Management organization (SMO) experience preferred

• A minimum of 5 years in or a combination of the following:

  • full-time experience as an administrator in a Medicare or state-level Medicaid program, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), large Health Care Organization, health plan, or any combination thereof

• Clinical practice experience.

• Experience with auditing and quality initiatives preferred

• Information Technology 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 apply all applicable licensing, regulatory, and industry standards.

Our Comprehensive Benefits Package

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.

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 Newtown Square, 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.