National Utilization Management Medical Director

Company: P3 Health Partners
Location: North Las Vegas
Posted on: January 23, 2023

Job Description:

We are looking for a National Utilization Management Medical Director. Ability to get licensed in Oregon, Nevada and Arizona. If you are passionate about patient care; eager to make a difference; and motivated to be part of a fast-growing organization then you should consider joining our team.National Utilization Management Medical DirectorJob Description: (Can work remotely)Leads develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes.Identifies and develops opportunities for innovation to increase effectiveness and quality.Provide clinical expertise across the enterprise for various functions.Responsible for corporate and medical policy interpretation, recommendation, and review within recognized areas of responsibility.Advise and collaborate in the development of clinical programs.Provide clinical support and participate in utilization management, quality management, and care management programs in the respective areas and identify opportunities for improvement and efficiency.Assist with the design, development, implementation, and assessment of preventative care, quality, and health enhancement programs that support the appropriate use of clinical resources in the delivery of consistent high-quality medical care to drive HEDIS metric compliance.Provide clinical leadership for medical necessity reviews, application of clinical guidelines in decision making, and for health promotion and education programsAssist is establishing corporate and regional programs to enhance the quality of care reduce medical costs and achieve positive health outcomes.Serves as a clinical resource and subject matter expert to both clinical and non-clinical staff.Perform clinical reviews and conduct peer to peers.Conduct discussions with physicians in the P3 Health Partners network regarding HEDIS metrics, medical policies, utilization management, claims editing, use of resources, and quality.Perform clinical data review of HEDIS compliance and develop strategic initiatives to increase patient compliance.Perform high-dollar claims and complex case reviews.Participate in inter-rater reliability activities.Participate in committees and workgroups to achieve department and corporate objectives.Participate in health plan Joint Operating Committees.Qualifications:A doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O.) is required.Seven (7) years of clinical experience or any combination of education and experience, would provide an equivalent background.Two (2) years of previous medical director experience working for a health plan, medical group, or hospital in utilization management, quality management or medical management required.Current unrestricted state of Nevada, Arizona, Oregon, Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) license or ability to obtain the licenses.Board-certified or board eligible and working towards certification in a specialty approved by theAmerican Board of Medical Specialists or the American Board of OsteopathyCertification in Utilization Review and Health Care Quality & Management is preferred.Knowledge of HEDIS, NCQA, and CMS Stars ProgramsAbility to effectively communicate with external physicians and organizationsProven leadership, problem-solving and the ability to manage multiple priorities.Requires strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.Results-oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.Demonstrate skill with Microsoft Office Suite and web-based program.Understanding of health plan and medical group functions related to utilization, care, as well as HEDIS/STAR s and NCQA. Familiarity with CMS regulations and standards.Basic knowledge of evidence-based clinical decision support guidelines (Milliman/Inter Qual).Basic knowledge of CPT coding and guidelines and how they relate to quality data capture.Other related skills and/or abilities may be required to perform this job.All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, region, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.Equal Opportunity Employer/Protected Veterans/Individuals with DisabilitiesThe contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

Keywords: P3 Health Partners, North Las Vegas , National Utilization Management Medical Director, Healthcare , North Las Vegas, Nevada