Medical Director (Utilization Review)
Reporting to the Chief Clinical Officer (CCO), the Medical Director, Utilization Review will support the staff of the Office of Clinical Affairs in the medical oversight of prior authorizations, durable medical equipment and in-patient reviews. The position oversees the physicians who conduct medical reviews and would also participate in, credentialing, appeals and grievances and medical policy. In addition to leading the training and mentoring of the physician reviewer program, the medical director will support the CCO and Office of Clinical Affairs in developing and maintaining relationships with governmental organizations, regulatory groups, healthcare providers, and other external stakeholders in all matters related to medical management.
• Oversight of the utilization review operations including appeals and grievances
• Leads and mentors the physician reviewers and the physician review training program
• Supports the Office of Clinical Affairs in developing and supporting clinical initiatives to support department utilization management goals.
• Supports the physician reviewer training and performance management and maintains high quality reviews
• Monitors and leads the physician peer to peer review process in a collaborative manner with hospital physicians, medical directors, primary care physicians and nurse case managers in daily activities.
• Utilizes productivity and outcome dashboards to identify opportunity areas and develops continuous improvement activities therein.
• Participates in and chairs clinical committees as assigned by CCO.
• Collaborates directly with the VP and Director of UM to create efficient, effective and high quality medical review processes.
• Clinical lead in developing and implementing evidenced based clinical policies and practices
• Participate in the development and maintenance of an effective medical policy program.
• Assist in the review of utilization data to identify variances in patterns and provide feedback and education to staff and providers.
• Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards
• Participates in the credentialing committee and collaborates with the leadership of UM to evaluate the performance of UM vendors on an on-going manner.
• Assure meeting state, federal and accreditation requirements
• Participate in the development, implementation, and revision of corporate level initiatives.
• Collaborate with market/product leaders to help define market strategy
• Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.
• Conducts review of prior authorizations, concurrent reviews, retrospective reviews and appeals to ensure members receive appropriate and medically necessary care in the most cost-effective setting
• Conduct peer to peer collaboration with hospital physicians, medical directors, primary care physicians and nurse case managers as required during the review process.
• Assures clinical expertise needed to support BMC HP is available to perform reviews.
• Direct supervision of full time, part time and per diem physician reviewers .
• Graduate as a Medical Doctor from an accredited college of medicine is required.
• Current board certification in ABMS or AOA specialty
• Active, unrestricted physician state license
• Current unrestricted license as an MD in the Commonwealth of Massachusetts is preferred.
• Utilization coverage reviews
• Applying evidence-based medicine (EBM) and managed care principles
• Referencing and applying drug compendia and evidence based medicine information systems
• 5+ years clinical practice
• Clinical experience in both adult and pediatric population preferred.
Competencies, Skills, and Attributes:
• Excellent demonstrated clinical skills and knowledge.
• Excellent written and verbal communication skills.
• Comprehensive knowledge of accrediting organizations such as NCQA.
• Comprehensive knowledge of InterQual protocols, HEDIS, and other quality measures.
• Knowledge of Medicare and federal/state Medicaid regulations, guidelines, and standards.
• Proven leadership skills and relationship building.
• Demonstrated ability to lead a team.
• Demonstrated knowledge of managed care principles and processes.
• Ability to work independently with intermittent supervision.
• Adhere to appropriate turn-around-times and deadlines while maintain results of high quality and reliability.
• Administrative experience preferred
• Ability to travel to locations within New Hampshire and Massachusetts.
• Regular and reliable attendance is an essential function of the position.