Medical Director Utilization Management, Pediatrics, REMOTE

Your career starts now. We are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Responsibilities:

The Medical Director, Utilization Management 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, Medical Affairs.

;The following responsibilities are in regard to enrollees 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 provider performance against standards of high quality, especially the performance standards embodied in the HEDIS program.
• Assuring a high-performing Medical Management system that adheres to the terms of contracts and all relevant regulatory requirements. ;
• Utilizing evidence-based standards in making coverage determinations.
  
  

Accountabilities:

• Ensures the provision of quality and clinically sound services to all Enrollees by associates and Providers.
• Serves as medical advisor and manager for all clinically related activities.
• Assures that organization medical policies and procedures adhere to contractual obligations.
• Performs clinical case reviews in conjunction with Medical Excellence Department.
• Demonstrates knowledge of prescribed and established medical procedures and practices.
• Maintains familiarity with federal, state and local regulations that may pertain to the medical and clinical operations. Provides leadership in the development and implementation of medical policy as it relates to health management.
• Maintains compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations.
• Manages day-to-day operations and monitors the integration and processing of members to optimize appropriate use of behavioral and physical health services.
• Participates with Quality Improvement and Medical Excellence in the identification and analysis of medical and behavioral health information in order to develop interventions to improve clinical effectiveness of medical management strategies.
• Works closely with a multidisciplinary team to ensure behavioral health management and quality management programs are meeting contractual obligations.
• Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff.
• Trains staff on medical issues and provide consultation to staff as appropriate.
• Assists IHCM Managers in assessing members’ need for case management services
• Attends case management meetings and monthly rounds as scheduled.
• Collaborates with the integrated case management team, during scheduled meetings and informally as needed
• Thoroughly documents all care coordination activity in the member medical record in the electronic case management documentation system.;
• Adheres to AmeriHealth Family of Companies (ACFC) policies and procedures and supports and carries out the ACFC mission and values
• Other duties as assigned.
  
  

Education/Experience:

• Doctor of Medicine (MD) licensed to practice as a medical director; additional state licensure required in all states where ACFC has a line of business and that application is expected within 30 days of hire.;
• Current Pennsylvania license preferred.
• Must be Board-certified in Pediatrics. Must be clear of any sanctions by the applicable state or Office of the Inspector General.
• Must not be prohibited from participating in any Federally or State funded healthcare programs.
• MHA, MPH, or MBA in healthcare management preferred.
• Minimum of 3 years of utilization management experience in a Medicaid, Medicare, dual eligible or commercial health plan preferred.
• Minimum of 5 years of clinical practice experience.
• Proficiency utilizing MS Office (Word, Excel, Outlook), internet applications, and electronic medical record and documentation programs.
• Will be responsible for weekend call and holiday coverage as assigned across the team.
• Able to work Monday through Friday from 8:30a to 5p within the time zone of residence.
  
  

Other Skills:

• Strong written and oral communication skills-required.
• Demonstrated competency in use of healthcare data.
• Demonstrated excellent interpersonal communication skills and presentation skills.
• Experienced in conflict resolution and negotiation.
• Understanding of and expertise in quality improvement and medical economics.
• Strong leadership skills.
• Excellent analytical and problem solving skills.
• Demonstrated ability to access department’s work quality and develop / implement process improvements to achieve regulatory and oversight compliance.
• Maintain current knowledge of and applies all applicable licensing, regulatory and industry standards.; ; ; ;;
  
  

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.