Provide medical leadership for utilization management, medical review, and quality improvement activities, with a focus on complex, controversial, or high-cost cases. Review medical necessity appeals, claims, and utilization patterns while supporting care decisions for high-risk members and capitated provider programs.
Key Responsibilities
- Direct utilization management, quality improvement, and credentialing activities for the business unit.
- Review complex, controversial, and experimental services to support timely medical necessity determinations.
- Conduct rounds and coordinate care for high-risk patients with care management teams.
- Collaborate with network providers, appeals staff, and medical and pharmacy consultants on complex cases.
- Support performance improvement initiatives for capitated providers and value-based care processes.
- Identify utilization trends, adverse patterns, and opportunities to improve quality and cost of care.
- Review claims involving unusual or new services to determine medical necessity and appropriate payment.
- Assist with physician committees, provider education, and implementation of medical management policies.
Required
- MD or DO degree.
- Current unrestricted state medical license.
- Board certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association’s Department of Certifying Board Services.
- Active clinical practice.
Preferred
- Experience in utilization management.
- Knowledge of quality accreditation standards.
- Board certification in Internal Medicine or Family Medicine.
- Experience caring for culturally diverse populations.
- Coursework in health administration, health financing, insurance, or personnel management.
Benefits & Perks
- Competitive pay with a posted salary range.
- Comprehensive benefits package including health insurance, 401(k), and stock purchase plans.
- Tuition reimbursement.
- Paid time off plus holidays.
- Flexible remote, hybrid, field, or office work schedules.
- Potential additional incentive compensation.