Per Diem Health Plan UM Medical Director

Education: MD or DO required

Licenses and Credentials:

• Physician - Massachusetts active full license required

Experience:

• 5+ years of Health Plan UM experience
• at least 5 years of clinical practice experience

Knowledge, Skills and Abilities:

• Utilization Management experience
• Excellent written and oral communications skills
• Proficient in basic computer skills, use of EHR's, digital tools
• Multitasking abilities
• Adaptable to change due to business growth

Job Description:

• Handles utilization management initial determinations, appeals and grievances within the scope of their expertise as defined by Medicare, MassHealth, NCQA and the Division of Insurance and within the compliance requirements of key regulatory and accreditation entities
• Use CMS, state and internal medical necessity policies to guide MN determinations
• Complete peer to peer case discussions with requesting providers as assigned
• Refer to IRO/external review if specialist match or expertise is needed
• Interact, communicate and collaborate with network and community physicians, hospital leaders and other vendors regarding care and services for enrollees
• Monitors performance metrics to identify areas for continuous improvement and ensure compliance
• Establishes and maintains positive relationships with colleagues and customers and gains their trust and respect
• Ensure diversity, equity and inclusion are integrated as a guiding principle

Other duties as assigned with or without accommodation

• Primarily remote position
• M-F 830-5pm EST
• Ensures that all assigned work is completed within regulatory timelines
• Checks and addresses assigned work queues, email, Teams messages during assigned work hours