Director of Utilization Management – M.D. – Orange County, CA

Our client is looking for a Utilization Management Medical Director to partner with the UM clinical operations team. The UM Medical Director oversees daily utilization management and directs the medical care of our members on behalf of our clients and serves in a supporting role as medical manager and policy advisor to the company and our clients.
The UM Medical Director is accountable for and provides professional leadership and direction to the utilization/cost management and clinical quality management functions. Works collaboratively with Market Medical directors and other functions that interface with medical management such as provider relations, member services, benefits and claims management.

 

Requirements Include:

  • M.D. graduate of an accredited medical school, MBA or advanced degree in healthcare management preferred
  • U.S. M.D. licensure
  • 2+ years experience as a physician reviewer performing peer review activities.
  • 3+ years experience in clinical practice in a primary care setting
  • Progressive medical administration experience strongly preferred
  • Proven ability in a medical leadership position in clinical credibility with  experience developing and guiding team members
  • A strong understanding of all aspects of managed care, including HMOs, PHOs, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, pharmacy management, and patient centered medical home concepts.
  • Strong interpersonal, verbal, and written communication skills.
  • The ability to navigate in a corporate matrix environment

 

Duties Include:

The Director of Utilization Management will:

  • Oversee daily utilization management activities including reviewing requests and making coverage determinations for services and supplies for delegated lines of business.
  • Act in a supporting role as medical manager and policy advisor to the company and our clients.
  • Executes the Utilization/Cost Management Programs and relevant Clinical Quality Improvement Programs in partnership with the Director, Care Management and Market Medical Directors
  • Interfaces with provider community on Utilization Management and evidence based medicine
  • Provides education to provider teammates in local markets and to the UM team regarding managed care processes as well as clinical issue

 

Benefits:

  • Salary range  $260k – $280K
  • Full benefits package
  • Bonus package based on experience
  • Relocation package for the right candidate; local candidates preferred

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