Utilization Management Medical Director

US-Irvine, CA or Chicago, IL
Req No.
2017-2092
Category
Clinical/Medical
Type
Regular Full-Time

Overview

Concerto delivers comprehensive care to Medicare, Medicaid, and complex-needs patients. For over a decade, we have provided extraordinary outcomes for thousands of people in these underserved groups.

The Concerto name reflects our unique approach to healthcare. It’s about how we work in concert with patients, providers, and health plans. It’s about the harmony of a patient’s care, health, and dignity.

 

Concerto Healthcare is looking for a Utilization Management Medical Director to partner with the UM clinical operations team.  The UM Medical Director oversees daily utilization management and directs the medical care of our members on behalf of our clients and serves in a supporting role as medical manager and policy advisor to the company and our clients. The UM Medical Director is accountable for and provides professional leadership and direction to the utilization/cost management and clinical quality management functions. Works collaboratively with Market Medical directors and other functions that interface with medical management such as provider relations, member services, benefits and claims management.  Assists (as determined by Managing Director of UM in coordination with SVP, Clinical Delivery & Operations) in short and long range program planning, total quality management (quality improvement) and external relationships. Works with Clinical Delivery and Operations leadership to support, and provide assistance and direction in overall medical management effectiveness. Monitors all issues of clinical quality management as it related to UM functions and operates within in the confines of the quality oversight policies and procedures.  Collaborates with Concerto Healthcare Market Medical directors around evidence-based practices and medical policies and carries out Concerto Healthcare medical policies.

Responsibilities

  • Responsible and accountable to the Corporate Senior Medical Director of Operations, Utilization Management for helping to manage health plan medical costs and assuring appropriate health care delivery for client health plans, products and services. Reports organizationally to the Senior Medical Director of Operations.
  • Supports design and implementation of medical policies, and appropriate UM goals and objectives.
  • Interfaces with provider community in regards to Utilization Management and evidence based medicine
  • Provides professional leadership and direction to the functions within the Utilization Management Department
  • Responsible and accountable for executing the Utilization/Cost Management Program and relevant Clinical Quality Improvement Programs in partnership with the Managing Director, Utilization Management and Market Medical Directors.
  • Assists the Market Medical Directors with activities to promote positive community relations.
  • Assures plan conformance with legal and regulatory requirements.
  • Assists the Market Medical Directors in creating and maintaining a system that gives feedback to providers individually and collectively regarding managed care effectiveness of individual providers and networks.
  • Assists the Market Medical Directors and in designing and implementing corrective action plans to address issues and improve plan and network managed care performance.
  • Collaborates with Market Medical Directors in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes.
  • Participates in policy review, performs analysis and makes recommendations.
  • Participates in the retrospective review and analysis of Plan performance from summary data of paid claims, encounters, authorization logs, compliant and grievance logs and other sources.
  • Achieves and maintains Fidelis’ benchmarked utilization and cost management (UM) goals and clinical quality improvement (QI) objectives.
  • Provides periodic written and verbal reports and updates regarding Utilization Management as required in the Quality Management Program description, the Annual Work Plan and Community Care policy and procedures to various plan committees, the health plan Market Medical Director.
  • Supports URAC, AHCA and NCQA qualification activities.
  • Assists in preparation for site visits and responds to accrediting and regulatory agency feedback.
  • Supports pre-admission review, utilization management, and concurrent and retrospective review process. Participates in risk management, claim adjudication, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orientation, etc.
  • Conducts and/or supports quality improvement and outcomes studies related to Utilization Management as directed by the state Departments of Health, the Quality Management Committee, Medical Advisory Committee, Peer Review Committee and management. Reports findings.
  • Monitors member and provider satisfaction survey results with the UM process and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.
  • Assists, as appropriate, with the contracting process of providers, hospitals, ancillary providers, and emergency and other support services, and evaluates the medical aspects of provider contracts.
  • May chair or assist in chairing (or delegates leadership of) Advisory Committees of the health plan which include (but are not limited to) the Peer Review Subcommittee and the Credentialing Subcommittee of the Quality Management Committee.
  • Participates in key marketing activities and presentations.
  • Promotes wellness and ensures programs of prevention, education and outreach to members and providers consistent with company’s mission, vision and values.
  • Maintains up-to-date knowledge of new information and technologies in medicine and their application to the health plan.
  • Contributes to and oversees in-service training and education of professional staff.
  • Represents at medical group meetings, conferences, etc. as appropriate and requested by Managing Director and/or Market Medical Directors
  • Participates in the development of strategic planning for existing and expanding business.
  • Recommends changes in program content in concurrence with changing markets and technologies.
  • Participates in key marketing activities and presentations, as necessary, to assist the marketing and branding efforts.
  • Ensures that the Utilization Management Program is available on a 24 hour basis to respond to authorization requests for emergency and urgent services and is available, at a minimum, during normal working hours for inquiries and authorization requests for non-urgent health care services.

Population health – collaborative care management leadership

  • Assists in assuring appropriate health care delivery for the assigned membership and managing the medical costs associated with the assigned population.
  • Helps recruit, develop and motivate population health-care management staff, as requested or appropriate.
  • Promotion of managed care systems using evidence-based medicine to educate and facilitate best practices with care management staff and medical providers
  • Understand and supports stratification, continuous evaluation and re-stratification of population for appropriate resource allocation.

Physician and provider relationship management

  • Responsible leading compliance with physicians and other providers to improve the quality and efficiency of care in the network and integrate these providers into our clinical initiatives.
  • Coordinates utilization review activities (by either by Fidelis staff or contracted utilization management care managers) at client facilities on a regular basis, identifies key issues facing leaders and works collaboratively with leadership to accomplish mutually agreed upon goals.
  • Creates and maintains a system that gives feedback to providers individually and collectively regarding managed care effectiveness of individual providers and networks and coordinates corrective actions with Market Medical Directors.
  • Nurtures a culture where delivering the highest quality yields lowest cost.
  • Provides critical thinking for analysis, evaluation and modification of data reports (e.g., medical, pharmacy, quality) and assist Fidelis stakeholders with the translation of information to knowledge and action to contracted physicians and providers.
  • Develop, maintain and grow relationships with key clinical leaders with the assigned market.

Quality of care and service delivery

  • Provides guidance and interpretation on issues of medical appropriateness, benefit application as appropriate, level of care necessary to include out-of-network care.
  • Maintains up-to-date knowledge of new information and technologies in medicine and their application to Fidelis’ s clients
  • Evaluates and ensures systems and processes to assist providers with adherence to evidence based protocols
  • Chairs or staffs peer review committees and
  • Participates in the Appeals and Grievance process, as necessary, to assure timely, accurate responses to members
  • Assures compliance related to Federal (e.g., CMS), State (e.g., Insurance commission) and local rules and regulations.

 

Qualifications

Required:

  • Graduate of an accredited medical school. M. D. Degree is required. MBA, or a Master's Degree is preferred in healthcare, or other related fields of study.
  • 3-5 years of clinical practice in a primary care setting and progressively responsible medical administrative experience preferred.

Preferred:

  • Proven ability in medical leadership position possessing clinical credibility with peers and the ability to be a team player and team builder.
  • A thorough understanding of all aspects of managed care, including HMOs, PHOs, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, pharmacy management, and patient centered medical home concepts.
  • Excellent interpersonal, verbal, and written communication skills.
  • Consistently completes continuing education activities relevant to practice area and needed to maintain licensure.
  • Ability to navigate in a corporate matrix environment.

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