$100K — $150K *
The essential job functions of this position are:
• Assists with oversight of clinical decision making aspects of the UM program, with the goals of keeping patients safe, improving quality of care, and enhancing affordability of care.
• Reviews and decides UM cases, reducing waste, ensuring that all requests for services and resources meet medical necessity criteria, and are medically prudent.
• Participates in peer to peer discussions with physicians requesting pre-certifications/ authorizations or other medical necessity determinations.
• Provides guidance for clinical operational aspects of the program.
• Actively participates/ facilitates Quality and Utilization Management Committees.
• Participates in setting policies and procedures for the Utilization Management department.
• Collaborates with internal and external entities to improve accessibility standards and quality practice standards to enhance value across the service delivery system (inpatient, emergency departments, urgent care services and practitioner office settings).
• Maintains a mutually professional relationship with physicians, hospital personnel, social services, agencies, etc.
• Assists in ensuring that Utilization Management Program policies and procedures meet regulatory requirements.
• Maintains relationships with key leaders and works to support their business strategies.
• Is accountable for the overall quality and affordability of care of the clinical programs and processes in concert with the VP of Expense Management.
• Is responsible for compliance with the policies and procedures, the standards of accrediting bodies and the regulations of state and local governing agencies.
• Is accountable for clinical excellence in providing managed care services that focus on quality patient care, timely provision of services, and cost-effectiveness.
• Comply with all compliance, regulatory and process training within the specified timeline.
• Perform other duties as assigned.
The ideal candidate will possess the following qualifications:
• Graduate of an M.D. or D.O. program required.
• 5 years of general medical clinic practicing physician experience required.
• 5 years of board certified medical specialty or medical practice experience preferred.
• 2 years of Utilization Management experience including MA medical review, peer to peer, and physician/ facility liaison functions preferred.
• MD - Medical Doctor State of Texas, DO - Doctor of Osteopathic Medicine State of Texas, or other American Board of Medical Specialty Certification in respective area required upon hire.
Valid through: 8/26/2020