This physician leader oversees utilization management, quality improvement, and medical review activities for members, with a strong focus on medical necessity, cost containment, and timely decisions on complex cases. The role includes reviewing high-risk patients and claims, supporting capitated provider performance improvement, and collaborating with care management, network providers, appeals, and pharmacy/medical consultants. It is a leadership position for an actively practicing, board-certified physician who helps shape policy, physician education, and physician committee work.
Key Responsibilities
- Direct medical management, quality improvement, and credentialing functions for the business unit.
- Conduct utilization review, quality assurance, and medical review for complex, controversial, or experimental services.
- Provide medical leadership for utilization management, cost containment, and quality improvement initiatives.
- Perform regular rounds for high-risk patients and coordinate care with care management teams.
- Collaborate with clinical teams, network providers, appeals staff, and medical and pharmacy consultants on complex cases and medical necessity appeals.
- Review claims and determine medical necessity and appropriate payment for unusual or new services.
- Support physician committees, provider education, and implementation of quality and utilization management policies.
- Identify utilization trends, provider practice patterns, and clinical quality improvement opportunities.
Required
- MD or DO degree.
- Board certification in a medical specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association.
- Current unrestricted Arizona medical license.
- Active clinical practice.
Preferred
- Utilization management experience.
- Knowledge of quality accreditation standards.
- Coursework in health administration, health financing, insurance, or personnel management.
- Experience treating or managing care for a culturally diverse population.
Benefits & Perks
- Competitive pay with a posted salary range of $225,700 to $428,900 per year.
- Comprehensive benefits package including health insurance, 401(k), and stock purchase plans.
- Tuition reimbursement, paid time off, and holidays.
- Flexible work approach with remote, hybrid, field, or office schedules.