Reporting to the Chief Medical Officer (CMO), the Medical Director, Utilization Management (UM) will support the staff of the Office of Clinical Affairs in all areas of medical management including utilization review and management, care management, credentialing, quality management, appeals and grievances, pharmacy management and network management. In addition to  leading the  training and mentoring of the physician reviewer program, the medical director will support the CMO 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. 

KEY FUNCTIONS/RESPONSIBILITIES:

ADMINISTRATIVE RESPONSIBILITIES:

• Supports the utilization management operations lead in the oversight of the utilization management 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 IRR process.
• Leads the physician peer to peer review process to support utilization management collaboration with hospital physicians, medical directors, primary care physicians and nurse case managers in daily activities.
• Along with the utilization management operations lead regularly reviews the utilization management performance dashboards.
• Participates in and chairs clinical committees as assigned by Chief Medical Officer.

CLINICAL RESPONSIBILITIES:

• Conducts review of prior authorizations, concurrent reviews and retrospective reviews that do not meet standard criteria and determines coverage.
• Conduct peer to peer collaboration with hospital physicians, medical directors, primary care physicians and nurse case managers as required during the review process.

QUALIFICATIONS:

Education:

• Graduate as a Medical Doctor from an accredited college of medicine is required.

Experience:

• 8-10+ years of related experience is required including a minimum of 5 years direct clinical experience and a minimum of 3 years of experience in medical management, specifically utilization management in a managed care setting.
• Clinical experience in both adult and pediatric population preferred.

Certification or Conditions of Employment:

• Board certification in recognized medical specialty.
• Current unrestricted licensure as an MD.
• Current unrestricted licensure as an MD in the Commonwealth of Massachusetts is 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 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.

WORKING CONDITIONS AND PHYSICAL EFFORT:

• Ability to travel to locations within New Hampshire and Massachusetts.

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

Required Skills Required Experience