Market Medical Director, Utilization Management - WellMed - Remote

WellMed, part of the Optum family of businesses, is seeking a Market Medical Director, Utilization Management to join our team in Dallas, Austin, San Antonio, El Paso, Tampa, Orlando, Miami, Atlanta, or Savannah. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.

At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

The Market Medical Director for Utilization Management will support WellMed Medical Management, Inc.

Primary Responsibilities:

• Assists in development and maintaining an efficient UM program to meet the needs of the health plan members and commensurate with company values
• Educates primary care physicians regarding systems, structures, processes and outcomes necessary for assurance of regulatory compliance related to market activities
• Develops strategies for improving all aspects of market performance including RAPS, membership, and medical management
• Participates in case review and medical necessity determination
• Conducts post service reviews issued for medical necessity and benefits determination coding
• Analyzes aggregate data and reports to primary care physician
• Serves as the liaison between physicians and health plan Medical Directors
• Supervises the functions of Care Coordination
• Assesses the effectiveness of the specialty network to ensure members have access to multi-specialties within their demographic area
• Represents the providers as an influence to the credentialing committee
• Reviews policies and procedures of credentialing department and offers guidance for revision and implementation of process
• Educates primary care network and assists in problem resolution
• Assists in development of medical management protocols
• Performs analysis of utilization data and suggests/implements corrective action plans with network physicians
• Performs all other related duties as assigned

Required Qualifications:

• Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), or M.B.B.S.
• Board Certified in Family Medicine or Internal Medical
• Unrestricted licensed in Texas or Florida
• 5+ years of post-residency clinical practice experience
• Proficiency with Microsoft Office applications

Preferred Qualifications

• Unrestricted license in New Mexico (in addition to above)
• 2+ years of experience in utilization management activities
• 2+ years of experience with acute admission experience
• 2+ years of experience working in a managed care health plan environment
• Bilingual (English/Spanish) fluency