Is the Medical Director Utilization Management position at Amerihealth Caritas fully remote?

Yes, this Medical Director Utilization Management position at Amerihealth Caritas is a remote position. The role is available for candidates in United States.

Is this a full-time or part-time Medical Director Utilization Management role?

This is a full-time Medical Director Utilization Management position at Amerihealth Caritas.

What benefits does Amerihealth Caritas offer for this position?

Amerihealth Caritas offers the following benefits: Paid Time Off, Health Insurance, Tuition Reimbursement.

How do I apply for the Medical Director Utilization Management position at Amerihealth Caritas?

You can apply for this Medical Director Utilization Management position by clicking the "Apply Now" button on this page, which will take you to Amerihealth Caritas's application portal.

Medical Director Utilization Management at Amerihealth Caritas

United States

In this role, you will lead the operational areas of the Utilization Management (UM) program including prospective, concurrent, and retrospective reviews. As a Medical Director, UM you ensure all patient care decisions and referrals are medically appropriate by using national and local criteria. Our Medical Directors, UM help develop and implement medical policies, procedures, and clinical guidelines aligned with contractual obligations and regulatory guidelines. They partner with Quality Improvement teams to analyze utilization trends and develop interventions to improve clinical effectiveness. Medical Directors, UM also serve as a key point of contact for physicians and providers, conducting peer-to-peer discussions to facilitate collaborative care and resolve issues. In addition, you will collaborate with Corporate Medical Directors, our Utilization and Case Management RNs and staff, and the Vice President, Medical Affairs.Work Arrangement<ul><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Fully remote; must be willing to work rotational weekend and holidays.</li></ul>Responsibilities<ul><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Ensures quality and clinically sound services for all enrollees through associates and providers.</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Serves as medical advisor and manager for all clinically related activities</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Ensures that the organization’s medical policies and procedures adhere to contractual obligations</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Performs clinical case reviews in conjunction with the Medical Excellence Department.</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Demonstrates knowledge of prescribed and established medical procedures and practices</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Maintains familiarity with federal, state, and local medical and clinical operations regulations. Provides leadership in developing and implementing medical policy related to health management, compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Manages day-to-day operations and monitors the integration and processing of members to optimize the appropriate use of behavioral and physical health services.</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Participates with Quality Improvement and Medical Excellence in identifying and analyzing medical and behavioral health information to develop interventions to improve the clinical effectiveness of medical management strategies. Work closely with a multidisciplinary team to ensure behavioral health management and quality management programs meet contractual obligations</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Trains staff on medical issues and provides consultation to staff as appropriate</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Assists Care Managers in assessing members’ needs for case management services and attends meetings and monthly rounds as scheduled</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Collaborates with the integrated case management team during scheduled meetings and informally as needed</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Thoroughly documents all care coordination activity in the member’s medical record in the electronic case management documentation system</li></ul>Education and Experience<ul><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) required</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Master of Health Administration (MHA), Master of Public Health (MPH), or Master of Business Administration (MBA) in Healthcare Management preferred</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">A minimum of three years of utilization management or appeals experience in a Medicaid, Medicare, and/or dual eligible</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">A minimum of five years of clinical practice experience required in family medicine, pediatrics, internal medicine, surgery, neonatology, or physiatry</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Proficiency utilizing MS Office Suite, internet applications, and electronic medical record and documentation programs</li></ul>Licensure<ul><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) that is active and in good standing.</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Must be able to obtain Pennsylvania license within 120 days of hire. </li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Additional medical licensure is required in all states where AmeriHealth Caritas has a line of business. The application is expected to be initiated within 30 days of hire.</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Candidates must be board certified in their specialty. Must be clear of any sanctions by the applicable state or the Office of the Inspector General.</li><li style="line-height:18.0px;margin-bottom:0.0px;margin-right:0.0px;margin-top:0.0px;padding:0.0px;">Must not be prohibited from participating in any Federally or state-funded healthcare programs.</li></ul>Our Comprehensive Benefits PackageFlexible 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 are looking for the next generation of health care leaders.At AmeriHealth Caritas, we are 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 would like to connect with you.Headquartered in Newtown Square, Pennsylvania, 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.

Apply Now

Remote Opportunity

Medical Director Utilization Management

Join Amerihealth Caritas as a senior professional working remotely from United States. Explore the role, benefits, and apply in one place.

Medical Director Utilization Management

Amerihealth Caritas

Full Time

3 weeks ago

United States

Engineering

Senior

Utilization Management

Medical Policy Development

Quality Improvement

+5 more

Job Description

In this role, you will lead the operational areas of the Utilization Management (UM) program including prospective, concurrent, and retrospective reviews. As a Medical Director, UM you ensure all patient care decisions and referrals are medically appropriate by using national and local criteria. Our Medical Directors, UM help develop and implement medical policies, procedures, and clinical guidelines aligned with contractual obligations and regulatory guidelines. They partner with Quality Improvement teams to analyze utilization trends and develop interventions to improve clinical effectiveness. Medical Directors, UM also serve as a key point of contact for physicians and providers, conducting peer-to-peer discussions to facilitate collaborative care and resolve issues. In addition, you will collaborate with Corporate Medical Directors, our Utilization and Case Management RNs and staff, and the Vice President, Medical Affairs.

Work Arrangement

Fully remote; must be willing to work rotational weekend and holidays.

Responsibilities

Ensures quality and clinically sound services for all enrollees through associates and providers.
Serves as medical advisor and manager for all clinically related activities
Ensures that the organization’s medical policies and procedures adhere to contractual obligations
Performs clinical case reviews in conjunction with the Medical Excellence Department.
Demonstrates knowledge of prescribed and established medical procedures and practices
Maintains familiarity with federal, state, and local medical and clinical operations regulations. Provides leadership in developing and implementing medical policy related to health management, 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 the appropriate use of behavioral and physical health services.
Participates with Quality Improvement and Medical Excellence in identifying and analyzing medical and behavioral health information to develop interventions to improve the clinical effectiveness of medical management strategies. Work closely with a multidisciplinary team to ensure behavioral health management and quality management programs meet 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 Care Managers in assessing members’ needs for case management services and attends 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’s medical record in the electronic case management documentation system

Education and Experience

Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) required
Master of Health Administration (MHA), Master of Public Health (MPH), or Master of Business Administration (MBA) in Healthcare Management preferred
A minimum of three years of utilization management or appeals experience in a Medicaid, Medicare, and/or dual eligible
A minimum of five years of clinical practice experience required in family medicine, pediatrics, internal medicine, surgery, neonatology, or physiatry
Proficiency utilizing MS Office Suite, internet applications, and electronic medical record and documentation programs

Licensure

Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) that is active and in good standing.
Must be able to obtain Pennsylvania license within 120 days of hire.
Additional medical licensure is required in all states where AmeriHealth Caritas has a line of business. The application is expected to be initiated within 30 days of hire.
Candidates must be board certified in their specialty. Must be clear of any sanctions by the applicable state or the Office of the Inspector General.
Must not be prohibited from participating in any Federally or state-funded healthcare programs.

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 are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are 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 would like to connect with you.

Headquartered in Newtown Square, Pennsylvania, 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.

Benefits

Paid Time Off
Health Insurance
Tuition Reimbursement

Skills

Utilization Management

Medical Policy Development

Quality Improvement

Behavioral Health Management

Regulatory Compliance

Clinical case reviews

Peer-to-peer discussions

Clinical effectiveness

Ready to Apply?

Join Amerihealth Caritas today

Posted 3 weeks ago

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