Medical Director in San Antonio, TX

$200K - $250K(Ladders Estimates)

UnitedHealth Group   •  

San Antonio, TX 78201

Industry: Healthcare


5 - 7 years

Posted 50 days ago

Position Description

The Market Medical Director for Utilization Management will support WellMed Medical Management, Inc. by making utilization management determinations, identifying utilization trends suggesting possible over or under utilization of services and proactively suggesting improvements to WellMed Medical Management's utilization management program. The position will also provide appropriate mentoring and leadership to physicians in the market as well as develop relationships to support growth and fiscal responsibility.

Primary Responsibilities:

  • Assists in development and maintaining an efficient UM program to meet the needs of the health plan members and commensurate with company values
  • Educates primary care physicians regarding systems, structures, processes and outcomes necessary for assurance of regulatory compliance related to market activities
  • Develops strategies for improving all aspects of market performance including RAPS, membership, and medical management
  • Participates in case review and medical necessity determination
  • Conducts post service reviews issued for medical necessity and benefits determination coding
  • Analyzes aggregate data and reports to primary care physician
  • Serves as the liaison between physicians and health plan Medical Directors
  • Supervises the functions of Care Coordination
  • Assesses the effectiveness of the specialty network to ensure members have access to multi-specialties within their demographic area
  • Represents the providers as an influence to the credentialing committee
  • Reviews policies and procedures of credentialing department and offers guidance for revision and implementation of process
  • Educates primary care network and assists in problem resolution
  • Assists in development of medical management protocols
  • Performs analysis of utilization data and suggests/implements corrective action plans with network physicians
  • Performs all other related duties as assigned

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • Doctor of Medicine (M.D.) degree
  • Board Certified/Board Eligible Family Practitioner or Internal Medical Specialist
  • 5+ more years of clinical practice experience
  • 2+ more years of experience in utilization management activities
  • Proficiency with Microsoft Office applications

Preferred Qualifications:

  • 2+ years of experience working in a managed care health plan environment
  • Bilingual (English/Spanish) fluency

Physical & Mental Requirements:

  • Ability to sit for extended periods of time
  • Ability to use fine motor skills to operate office equipment and/or machinery
  • Ability to receive and comprehend instructions verbally and/or in writing
  • Ability to use logical reasoning for simple and complex problem solving

Valid Through: 2019-10-24