11 utilization management medical director jobs found

Hi, we're Oscar. We're hiring a Behavioral Health Utilization Management Medical Director to join our Member Strategy & Ops team. Oscar is the first health insurance company built around a full stack technology platform and a focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.   About the role You will determine the medical appropriateness of behavioral health services by reviewing clinical information and applying evidence-based guidelines. This role is required to meet Oscar's contractual services to Cigna as part of our C+O partnership, for which Oscar is delegated for behavioral health utilization management services. The services performed by this role are central to both the compliance and accreditation of Oscar's utilization management program. You will report to the VP Medical Director, Member Programs. This is a remote /...

This role is eligible for a $10,000 sign-on bonus for external candidates. This role is 100% remote. Qualified candidates, regardless of geographic location, will be considered. The Medical Director provides organizational leadership in the operational areas of care management, utilization review, appeals, quality improvement and related policy and practice initiatives in collaboration with the Corporate Medical Director(s), Utilization Management and the Vice President, Utilization Management Physician. The following responsibilities are in regards to members with medical conditions and their providers: Identifying and implementing evidence-based practice guidelines throughout the provider network. Overseeing the quality of clinical care for network and non-network providers. Engaging the provider network in Continuous Quality Improvement through the diffusion of practice standards, and through an internal quality assurance program that measures network...

The Medical Director is responsible for providing clinical leadership within Sentara Health Plans, aligned to one or more plans. Accountable for monitoring utilization, case management and quality outcomes. The Medical Director collaborates with the Sentara Health Plans Chief Medical Director, Senior Medical Director(s) and Clinical Care Services (CCS) teams to establish, implement, and evaluate effectiveness of clinical programs to support members and meet the department goals. Medical Director activities further include support of the CCS nurses, Government services nurses, Pharmacy staff, Population Health and Quality Improvement Teams. Lastly, Medical Directors interact externally with network physicians, vended program clinical leaders, and government program leaders as required to improve the quality of clinical outcomes, cost efficiency and patient/member experience with the Health Plan and Health Systems with which we contract. Physical Location Optima...

Key member of the utilization management team, and provides timely medical review of service requests that do not initially meet the applicable medical necessity guidelines. Routinely interacts with physicians, leadership and management staff, other Physician Clinical Reviewers (PCR), and health plan members and staff whenever a physician`s input is needed or required. Directs daily involvement in the following utilization management functions: Reviews all cases in which clinical determinations cannot be made by the Initial Clinical Reviewer. Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory time frame of the request by phone or fax. Provides clinical rationale for standard and expedited appeals. Provides assistance and act as a resource to Initial Clinical Reviewers as needed to discuss cases and problems. Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD...

HealthHelp - A WNS Company (www.HealthHelp.com), is the leader in the field of healthcare utilization & care management. We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach. Our methodology helps payors achieve a higher return on investment, gives providers education programs that better inform physicians, and ensures quality and safety for the patients needing treatment. HealthHelp’s innovative approach and strong IT capability in specialty benefits management means that staff will move healthcare forward when provided with evidence-based solutions and second opinions. HealthHelp's staff is comprised of healthcare professionals who make a difference every day. HealthHelp has a desire to fill their company with talented and innovative people who want a career path filled with success and personal growth. Our specialty benefits management services are broad and include,...

Cohere Health is illuminating healthcare for patients, their doctors, and all those who are important in a patient’s healthcare experience, both in and out of the doctor’s office. Founded in August 2019, we are obsessed with eliminating wasteful friction that patients and doctors experience in areas that have nothing to do with health and treatment, particularly for diagnoses that require expensive procedures or medications. To that end, we build software that is expressly designed to ensure the appropriate plan of care is understood and expeditiously approved, so that patients and doctors can focus on health, rather than payment or administrative hassles. Opportunity Overview: We are looking for a Medical Director who will lead our Cardiology Associate Medical Directors and perform clinical reviews. Reporting to the Senior Medical Director for Cohere Health, and part of the review team that includes non-clinical intake specialists and nurses, this is a critical...

Key member of the utilization management team, and provides timely medical review of service requests that do not initially meet the applicable medical necessity guidelines. Routinely interacts with physicians, leadership and management staff, other Physician Clinical Reviewers (PCR), and health plan members and staff whenever a physician`s input is needed or required. Directs daily involvement in the following utilization management functions: Reviews all cases in which clinical determinations cannot be made by the Initial Clinical Reviewer. Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory time frame of the request by phone or fax. Provides clinical rationale for standard and expedited appeals. Provides assistance and act as a resource to Initial Clinical Reviewers as needed to discuss cases and problems. Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD...

Company Description: Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities.  We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.   Position Responsibilities: Specific Oversee the design and execution of health service-related functions within managed care plans Utilization Management Care Management Population Health Management Grievance and Appeals Provide direction and leadership, as required, to medical management programs, processes and workflows to meet operational goals and anticipate future strategic needs and support related...

Compassion. It’s the starting point for health care providers like you and it’s what drives us every day as we put our exceptional skills together with a real feeling of caring for others. This is a place where your impact goes beyond providing care one patient at a time. Because here, every day, you’re also providing leadership and contributing in ways that can affect millions for years to come. Ready for a new path? Learn more, and start doing your life’s best work. SM **$3,500 Sign on Bonus for External Candidates** Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that is improving the lives of millions. Here, innovation is not about another gadget; it is about making health care data available wherever and whenever people need it, safely and reliably. There is no...

UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm) You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: PDP (The appeals are in response to adverse determinations for medical services related to benefit design and coverage, medical necessity, and the application of clinical criteria of medical policies) Communicate with UnitedHealthcare medical directors regarding appeals decision rationales and benefit interpretations Actively participate in team meetings focused on communication, feedback, problem solving, process improvement, staff training and evaluation, and the sharing of program...

Quit Genius is the #1 digital clinic for substance addictions. We are on a mission to help 100 million people overcome tobacco, alcohol and opioid addictions by combining technology, healthcare and design. It’s an ambitious mission, but one we fully believe in and we hire people who share our aspirations and core values.    We are a global team of doctors, designers, engineers and researchers who are aligned by one common goal. Authenticity, creativity, purpose and thoughtfulness are at the heart of everything we do to deliver that goal, so finding exceptional people to come on the journey is everything to us. Quit Genius has scaled to dozens of health plans and employers, covering over 2 million lives and has already helped more than 750,000 members conquer their addictions. As of 2021, we have raised $78M from leading global investors and now work with 100+ world-class team members across our New York, London, and remote offices.   ...