Medical Director, Utilization Management

UPMC Senior Communities • $200K — $250K *
Pittsburgh, PA 15219In-Person
Healthcare
8 - 10 years of experience
Today
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Job Overview by Ladders

Qualifications

  • Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) from an accredited institution required
  • 5-10 years of clinical practice experience needed
  • Managed care experience is preferred
  • Board certification in Internal Medicine, Family Medicine, Geriatric Medicine, or Emergency Medicine is a plus
  • Active Pennsylvania Medical License required

Responsibilities

  • Provide leadership direction for provider credentialing processes
  • Devote sufficient time to the CHC-MCO for timely medical decisions, including after-hours consultations
  • Lead efforts to meet Quality Improvement and Care Management goals
  • Expedite reviews of medically urgent issues in line with Health Plan policies
  • Participate in daily utilization management and quality improvement reviews
  • Stay updated on professional standards in quality improvement and utilization management
  • Educate network providers on clinical guidelines and standards

Benefits

  • Fully remote work opportunity
  • Supportive environment for Quality Improvement and Care Management Programs
  • Opportunity to directly influence member outcomes and satisfaction
  • Involvement in external accreditation and certification activities
  • Opportunity for leadership within a collaborative team environment
Full Job Description
Purpose:
The UPMC Health Plan is seeking a Medical Director to join our Utilization Management team. The ideal candidate will have a minimum of 10 years of clinical experience, as well as experience working with a Health Plan.

The Medical Director, Utilization Management is responsible for assuring physician commitment and delivery of comprehensive high-quality health care to UPMC Health Plan members. This fully remote role will be responsible for assuring physician commitment and delivery of comprehensive high quality health care to UPMC Health Plan members. Oversees adherence to quality and utilization standards through committee delegations, and further establishes an effective working relationship between UPMC Health Plan's Network and its physicians, hospitals and other providers.

Responsibilities:

  • Provide leadership direction for provider credentialing processes.
  • Physicians must devote sufficient time to the CHC-MCO to provide timely medical decisions, including after-hours consultation, as needed
  • Provide leadership and direction in meeting Quality Improvement and Care Management goals directed at improvements in member health status outcomes and established business strategies.
  • Provide expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan.
  • Actively participates in the daily utilization management and quality improvement review processes, including concurrent, prospective and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns.
  • Keep current with accepted standards and professional developments in the areas of quality improvement and utilization management.
  • Communicate and educate network providers regarding clinical guidelines, pathways, protocols, and standards related to quality and utilization processes.
  • Responsible for reporting the communication of reportable communicable diseases in accordance with statute.
  • Interacts with physicians regarding opportunities to improve member satisfaction and compliance with Utilization Management and Quality Improvement policies and procedures.
  • Work with the DOH State and District Office Epidemiologists in partnership with the designated county/municipal health department staff to appropriately report reportable conditions in accordance with 28 Pa. Code 27.1 et seq.
  • Daily interventions support implementation of the Health Plan's Quality Improvement and Care Management Programs.
  • Represent the Health Plan in external accreditation and certification activities.
  • Act as first level physician reviewer for all cases referred by the Quality Improvement and Care Management Departments.
  • Daily activities support adherence to quality and utilization standards, and establish an effective working relationship between UPMC Health Plan's Network and its physicians, hospitals and other providers.


Qualifications:

  • Doctor of Medicine or Doctor of Osteopathy from an accredited school Required
  • The ideal candidates will have a minimum of 5-10 years of clinical experience
  • Managed Care experience preferred
  • Preference will be given to candidates with board certification in Internal Medicine, Family Medicine, Geriatric Medicine or Emergency Medicine
    Licensure, Certifications, and Clearances:
  • Doctor of Medicine (MD) OR Doctor of Osteopathic Medicine (DO)
  • PA Medical License

About UPMC Senior Communities

UPMC Senior Communities Careers

There has never been a better time to explore the diverse job opportunities at UPMC Senior Communities—the leading network of senior living facilities focused on innovative care and professional excellence.

Work You’ll Do

Join UPMC Senior Communities to assist in transforming the experience of aging through top-tier care and wellness programs. This is an opportunity to be part of a team that values leadership, diversity, and innovation in the healthcare sector. Lead in a unique role where skills in healthcare, empathy, and leadership converge to enhance the lives of seniors. UPMC Senior Communities stands at the forefront of the industry, integrating advanced technology and personalized care practices. Engage with a professional network of healthcare providers and administrators dedicated to pioneering improvements in senior living. Collaborate with over 3,000 dedicated professionals across various facilities.

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The program is designed to foster career growth through comprehensive training, leadership development, and diversity training. UPMC Senior Communities is committed to nurturing the professional growth of its team members through continuous education and opportunities for advancement.

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Be part of a culture that thrives on innovation and continuous improvement. UPMC Senior Communities employs a vast array of healthcare professionals and support staff, all dedicated to setting new standards in senior care.

Drive Change in Senior Healthcare

Deliver targeted solutions and personalized care that significantly improve the quality of life for residents. UPMC Senior Communities offers a platform for professionals to apply their expertise in a meaningful and impactful way.

Be Part of a Great Team

Work alongside a team that values compassion and professionalism, harnessing the collective capabilities to deliver exceptional care. UPMC Senior Communities promotes a collaborative environment where every team member’s contribution is valued.

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Advance your career within UPMC Senior Communities through a variety of pathways, from direct care positions to administrative roles. Enjoy robust benefits, professional development programs, and a supportive work environment that encourages long-term career growth.

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Discover how UPMC Senior Communities leads the way in senior healthcare innovation: - Implementing cutting-edge health technology to enhance resident care - Developing community-based programs that support holistic wellness

The UPMC Senior Communities Employment Promise

With a commitment to employee satisfaction and career development, UPMC Senior Communities ensures that all team members have the resources and support to succeed. Clients and their families rely on UPMC Senior Communities for compassionate and skilled care, making it a prime choice for those seeking meaningful employment in the healthcare sector.

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