Clinical Services is focused on driving measurable and meaningful improvement in the use of evidence - based medicine, patient safety, practice variation and affordability. In serving our Medicare, Medicaid, and commercial members & plan sponsors, our Clinical Services teams partner with our network of physicians, hospitals and other health care professionals to achieve these goals. We are committed to our mission of helping people live healthier lives. Join UnitedClinicalServices where you will work from home and you will help heal the healthcare system while doing your life's best work.(sm) The Market Medical Director for Utilization and Care Management; identifying utilization trends suggesting possible over or under utilization of services and proactively suggesting improvements to the utilization / care management leadership. Primary Responsibilities:Assists in development and maintaining an efficient UM program to meet the needs of the health plan members and commensurate with company valuesEducates primary care physicians regarding systems, structures, processes and outcomes necessary for assurance of regulatory compliance related to market activitiesParticipates in case review and medical necessity determinationConducts post service reviews issued for medical necessity and benefits determination codingSupervises the functions of Care CoordinationAssists in development of medical management protocolsPerforms analysis of utilization data and suggests / implements corrective action plans with network physiciansLeading a large Care Management staff in redesign efforts to support dynamic changes in approaches to care / utilization management Partnering with the Clinical Affordability team to support new innovative approaches to making healthcare more efficient and meaningful to PCPs and patients alike; ultimately bending the cost curve in regionAligning Care Management delivery with region budget and financial goalsDeveloping and cascading clinical outcome / improvement messaging to business units to foster tighter working cultureHelping set agendas/strategies and leading multifaceted teams of Physician Business Managers, Risk Adjustment RNs, and Quality RNsAssist driving aligned performance in largely an independently contracted provider network through the development of meaningful relationships, financial and quality incentives, best practices, forward thinking solutions to improve our value proposition to medical providers Assist in the identification and development of current / new best practices in support of continuous financial and quality improvementServe as an integral dyad partner interfacing with Corporate level support divisions, to include: Quality, Risk Adjustment, Cost and CarePerforms all other related duties as assignedCustomer ServiceOversees and insures physician compliance with UM planResponds to physicians in a prompt, pleasant and professional mannerRespects physician, patient, and organizational confidentialityEducates medical groups regarding UM policies, procedures and government - mandated regulationsProvides quality assurance and education of current medical technologies, review criteria, accepted practice of medicine guidelines, and UM policies and procedures with counsel when criterion are not metPersonal and Physician DevelopmentStrives to personally expand working knowledge of all aspects of the Regional UM / CM leadershipAn active participant in physician meetingsOrients medical directors to ensure understanding of company policy and resources available for physician supportAssists in the growth and development of subordinates by sharing special knowledge with others and promotes continued education classesAttends continuing education classes to keep abreast of medical advancements and innovative practice guidelines
Required Qualifications:Doctor of Medicine (M.D. / D.O.) degreeBoard Certified in trained specialtyFive or more years of clinical practice experience Two or more years of experience in utilization / care management activities Proficiency with Microsoft Office applications Preferred Qualifications:Two years of experience working in a managed care health plan environment Bilingual (English / Spanish) fluency Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 90,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm) Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Job Keywords: Market, Medical Director, Care Management, Utilization, Board Certified, Clinical Practice
Internal Number: 739316
About UnitedHealth Group
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.