Medical Director II, Utilization Management

📋 Description

• • As a Medical Director in Utilization Management at Devoted Health, you will play a pivotal role in shaping and executing an efficient and effective utilization management (UM) program, ensuring the appropriate use of medical services for our health plan members while upholding the company's core values.
• • This leadership position requires close collaboration with a diverse range of departments, including utilization management, clinical management, pharmacy, network management, data analytics, legal, and finance, to achieve overarching corporate objectives.
• • You will be instrumental in the development and ongoing maintenance of our UM program, tailoring it to meet the evolving needs of our member population and aligning with best practices in healthcare delivery.
• • A significant aspect of your role will involve performing comprehensive clinical reviews, encompassing areas such as Part A and B services, appeals, and quality of care assessments, ensuring adherence to established quality standards and evidence-based guidelines.
• • You will conduct crucial peer-to-peer discussions with physicians, fostering collaborative relationships and facilitating informed decision-making regarding patient care and resource utilization.
• • Active participation in inter-rater reliability activities is essential to maintain consistency and accuracy in clinical reviews and decision-making processes.
• • You will contribute to the analysis of utilization data, identifying trends, patterns, and opportunities for improvement within the UM program and broader clinical operations.
• • Providing appropriate mentoring and leadership to clinical teams is a key responsibility, fostering a supportive and growth-oriented environment that drives both individual and team success.
• • Developing strong relationships across departments will be vital to support the organization's growth trajectory and ensure fiscal responsibility in medical service delivery.
• • You will represent the UM department in various committees and workgroups, contributing clinical expertise and strategic insights to achieve departmental and corporate goals.
• • Offering clinical support and actively participating in utilization management, quality management, clinical services, and care management programs will be central to identifying and implementing improvements in efficiency and member care.
• • Serving as a clinical resource and subject matter expert to both clinical and non-clinical staff across the Devoted Health Plan will empower colleagues with the knowledge and guidance needed to navigate complex healthcare scenarios.
• • Active engagement in acute and post-acute clinical rounds will provide real-time insights and opportunities to influence care pathways and resource allocation.
• • You will lead discussions with physicians within the Devoted network, addressing critical topics such as medical policies, utilization management strategies, optimal use of resources, and quality of care standards.
• • This role offers a unique opportunity to blend clinical expertise with strategic leadership, directly impacting the quality, safety, and cost-effectiveness of healthcare for our members.
• • You will be at the forefront of ensuring that Devoted Health delivers high-value care, embodying our mission to treat every person like family.
• • The position demands a proactive approach to problem-solving, a comfort with navigating ambiguity, and a passion for developing and implementing innovative processes within a rapidly growing organization.
• • Your insights will be crucial in promoting population health initiatives and advocating for the smart allocation of scarce resources to achieve optimal health outcomes.
• • You will be a key player in maintaining the high standards of care and service that define Devoted Health, contributing to our mission of improving the health and well-being of older Americans.
• • This role is ideal for a physician leader who is motivated by the challenge of transforming healthcare and is eager to make a tangible difference in the lives of our members.