Medical Director - Utilization Management at UPMC

Pittsburgh, Pennsylvania, United States -

Full Time

Start Date

Immediate

Expiry Date

30 Dec, 25

Salary

0.0

Posted On

01 Oct, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Utilization Management, Quality Improvement, Clinical Guidelines, Policy Decision Making, Member Satisfaction, Process Improvement, Provider Appeals, Medical Review, Healthcare Standards, Communication, Education, Clinical Experience, Network Providers, Grievances, Concurrent Review, Prospective Review, Retrospective Review

Industry

Hospitals and Health Care

Description

The UPMC Health Plan is seeking a licensed MD or DO for a fully remote Medical Director, Utilization Management role. The Medical Director, Utilization Management is responsible for assuring physician commitment and delivery of comprehensive high-quality health care to UPMC Health Plan members. They will be responsible for assuring physician commitment and delivery of comprehensive high quality health care to UPMC Health Plan members. They will oversee adherence to quality and utilization standards through committee delegations and further establish an effective working relationship between UPMC Health Plan's Network and its physicians, hospitals and other providers. UPMC offers a premier benefits package, designed to care for your total well-being — physically, emotionally, and financially — paired with endless opportunities for career advancement and growth. Discover the culture, the teams, and the passions that drive us to make Life Changing Medicine happen. This is a full-time and full remote role. Responsibilities: Actively participates in the daily utilization management and quality improvement review processes, including concurrent, prospective and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns. Provide expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan. Keep current with accepted standards and professional developments in the areas of quality improvement and utilization management. Communicate and educate network providers regarding clinical guidelines, pathways, protocols, and standards related to quality and utilization processes. Interacts with physicians regarding opportunities to improve member satisfaction and compliance with Utilization Management and Quality Improvement policies and procedures. Contributes to process improvement within the Utilization Management department. Participates in activities to support policy decision making. Utilizes clinical experience to support departmental reviews. This position requires a Doctor of Medicine or Doctor of Osteopathy from an accredited school PA Medical license Required The ideal candidate will have 5-10 years of clinical experience, as well as managed care experience Internal Medicine, Family Medicine, or Emergency Medicine highly preferred Licensure, Certifications, and Clearances: Doctor of Medicine (MD) OR Doctor of Osteopathic Medicine (DO) UPMC is an Equal Opportunity Employer/Disability/Veteran

Responsibilities

The Medical Director will oversee utilization management and quality improvement processes, ensuring adherence to standards and effective relationships with network providers. They will also participate in policy decision-making and contribute to departmental reviews.