Utilization Management Medical Director

Company: The Judge Group
Location: El Paso
Posted on: January 15, 2022

Job Description:

Location: El Paso, TX
Salary: commensurate
Description: Our client is currently seeking a Utilization Management Medical Director for their site in El Paso, TX.
This is NOT a remote role, and to be considered, ALL applicants MUST reside locally to El Paso.
In this role, the Medical Director . . . - Guides the plan on strategic Medical Direction decisions and provides advice that has a significant impact on strategic planning. Possesses industry-wide authority and represents the organization externally. Is a widely recognized Medical Direction expert and thought leader by both internal and external community and is responsible for the technical leadership of a major department/multiple departments across a function. Implements medical policy. Establishes and implements policies and standards, evaluates new treatments, and conducts medical research to ensure the quality of the medical care provided to patients. Implements utilization and financial initiatives. Develops and manages efforts to improve and maintain cost and utilization trends. May manage a single management entity that is responsible for primary care center. Requires an MD, DO or DC with Texas Licensure.
POSITION SCOPE: - Medical Directors in UM will report to the Chief Medical Officer and will be a member of the Medical Director UM team. This physician will be responsible for completing UM determinations and assisting with appeals. This physician may also be responsible for assisting in the CM of our client's members
The Medical Directors in UM will work alongside their dyad partners, and the UM Clinical Operational team, and will be responsible for performing all key business and clinical initiatives regarding UM and CM.

RESPONSIBILITIES: - The UM Medical Directors support Medicare, Medicaid, CHIP and LTSS Business in Utilization Management and works with the clinical operations UM team in the development of skills related to their job.
Participate in a Queue for utilization management reviews including Part C prior authorization, inpatient concurrent review, post-acute care authorizations and concurrent reviews. To a lesser extent will also participate in the Queue for appeals.
Works collaboratively as a consultant to CM operations team to support customers in CM, not limited to, but includes participating in rounds.
The UM Medical Director team facilitates UM consistently and compliantly using benefit plan information, applicable CMS and state regulations, clinical guidelines, emerging codes, new trends and best practice principles.
Performs all proactive & reactive peer-to-peers prior authorization, inpatient concurrent review, post-acute prior authorization, and concurrent review.
Works to achieve quality outcomes for members with a focus on service and affordability.
The UM Medical Director team will help improve clinical outcomes through daily interactions with health care professionals using active listening education, excellent communication, and negotiation skills.
Works to achieve internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-arounds of coverage reviews and quality outcomes based on those review decisions.
Aware of the Appeal process as appropriate and supports the Appeals Medical Director team when necessary.
UM Medical Directors will be encouraged to achieve personal career growth by creating protected time for associated activities.
Participates in committees representing UM for the business where appropriate.
The UM Medical Director develops, refines, reviews, and acts upon utilization review reporting metrics both national and occasionally at the market level. These metrics should demonstrate operational effectiveness including financial analysis and provider and customer satisfaction analysis.

REQUIRED EDUCATION & EXPERIENCE: - Degree in Medicine from an accredited school and is licensed to practice medicine (Doctor of Medicine or Doctor of Osteopathic Medicine).
Current active unrestricted medical license in TEXAS
Current board certification in an ABMS or AOA recognized specialty.
A minimum of five years of clinical experience is required.
Minimum of five years of experience in medical management, utilization review, and case management in a managed care setting.
Previous experience managing nurses or employees preferred.

REQUIRED SKILLS: Knowledge of managed care products and strategies.
Ability to work within changing business environment and balance patient advocacy with business needs.
Experience with managing multiple projects in a fast-paced matrix environment.
Demonstrated ability to educate colleagues and staff members.
Successful experience and comfort with change management.
Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem-solving skills.
Successful ability to assess complex issues, to determine and implement solutions, and resolve problems.
Success in creating and maintaining cooperative, successful relations with diverse internal and external stakeholders.
Demonstrated sensitivity to culturally diverse situations, participants, and customers/members.

OTHER REQUIREMENTS: Proof of COVID vaccination

READ CAREFULLY: All qualified candidates must send an updated copy of their resume to Caroline Cristini at CCristini@judge.com for immediate consideration. Upon emailing Caroline or applying to this role, be on the lookout for an email from CCristini@judge.com to set up a phone screen (a phone screen is required in order to complete your application). If you do not have a phone screen set up, you will be unable to be considered by our client.

Looking forward to our conversation!
Regards, Caroline Cristini, National Healthcare Recruiter CCristini@judge.com
Contact: ccristini@judge.com
This job and many more are available through The Judge Group. Find us on the web at www.judge.com

Keywords: The Judge Group, El Paso , Utilization Management Medical Director, Healthcare , El Paso, Texas