Reporting to the Vice President of Medical Policy and Utilization Review, the Utilization Review Medical Director will be responsible for providing leadership and subject matter expertise to our utilization management group. This role is a key role in helping our organization provide high quality, equitable care to our rapidly growing membership. The incumbent will have significant experience with utilization review, ideally experience with public programming, and excellent clinical judgment. They will work well both independently and in conjunction with a diverse team, improving operations and efficiency, using excellent communication skills to interact with professionals internally and externally.
Primary responsibility for performing daily medical reviews, appeals as appropriate, correspondence regarding review determinations and physician peer review activities. • Discuss specific clinical issues with attending physicians and CCA clinicians • Document case review findings, actions, and outcomes in accordance with Utilization Management policies; meets health plan inter-rater reliability guidelines • Appropriately access clinical specialty panel physicians to assist in complex or difficult case • Ensure compliance with medical policy. Maintains compliance with all federal, state and local regulatory guidelines. • Serve as the lead for CCA’s Utilization Review functions working closely with other medical management team members. • Support the development of utilization management policy initiatives.
• Support the development and implementation of medical policy, including recommendations for modifications to enhance efficiency and effectiveness. • Partner with the VPUM to direct the efforts of the utilization review and pre-certification functions to accomplish objectives within policy and budget. • Serve as a clinical resource and coach for the utilization management team • Is available and accessible to the utilization management team throughout the day to respond to clinical issues • Monitor utilization reports, identifying changes in utilization or access patterns and monitor overall trends on a weekly basis • Provide education to internal care management and clinician staff • Provide clinical input to specific projects as required by the organization or vendors • Maintain working knowledge of current quality improvement issues and tools • Contribute to development of Medical Expense Action plans to implement tactics to address areas of concern and monitors progress towards goal • Interact with contracting and provider relations to ensure coordinated approach to delivery system providers • Support plan accreditation efforts as determined by Quality Management and Accreditation Team
MD or DO required. • Must be licensed to practice in MA. • Board-certified in their medical specialty, required. • Must be clear of any sanctions by the applicable state or Office of the Inspector General. • Must be eligible to participate in any federally or State funded healthcare programs. • Utilization management experience required. • 5 or more years of medical management and general management experience in a managed care environment is strongly preferred. • 2 or more years full-time experience practicing medicine 3 or more years in a combination of the following: o Full-time experience as an administrator in a Medicare or state-level Medicaid program, Health Maintenance Organization (HMO) o Preferred Provider Organization (PPO), large Health Care Organization, health plan or any combination thereof • Primary care discipline, prior experience as Associate Medical Director (or equivalent) or physician reviewer in a Managed Care Plan preferred. • Minimum five years of progressive business experience.
Working Conditions: Standard office environment
Language Requirements: English, bilingual preferred not required Equipment Utilized: Standard office equipment
Internal Number: 2019-2317
About Commonwealth Care Alliance
Do you want to be part of an organization that is not only committed to giving back to the community but is finding innovative way to do the best possible way?At Commonwealth Care Alliance, our vision is to lead the way in transforming the nation’s healthcare for individuals with the most significant needs. We provide health services to medically, socially, and behaviorally complex individuals as both a health plan and provider. The populations we serve demand great service, and that means we need high performing talent – from our frontline clinicians to our strategic operators.Our unique care model leverages social determinants of health and is designed to engage our members by developing trusted relationships with care partners. We deliver care both in our members’ homes and in our clinics across the state of Massachusetts. Our interdisciplinary care teams take a whole-person care approach and tailor care plans to the individual members’ social, behavioral, and medical needs. We leverage best-in-class technology where applicable to improve clinical outcomes and reduce costs for these costly populations.