Medical Director, Utilization Management at Bright Health
- Provides medical leadership for utilization management, cost containment, and clinical quality improvement activities.
- Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Engages in peer to peer conversations to guide and support deliver of evidence-based care. This includes review of complex, controversial or experimental medical services.
- Facilitates planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
- Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
- Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
- Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
- Participates in telephonic outreach for collaboration with treating providers. This will include discussion of evidence - based guidelines, opportunities to close clinical quality / service gaps, and care plan changes that can impact health care expenses.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Medical Doctor or Doctor of Osteopathy
- Board certification in Internal Medicine, Family Practice or other primary care specialty
- Active, unrestricted license to practice medicine in a state or territory of the United States, licensure in Arizona and Illinois preferred
- This position requires strong clinical knowledge to support review for medically appropriate utilization of medical services and case management with a minimum of five (5) years of clinical practice. Administrative or managed care experience is highly desirable.
- This position requires strong interpersonal skills to generate collaboration and enable independent decision making among internal and external clinical staff.
- Review determinations for medical necessity
- Support peer to peer conversations for authorization, appeal and concurrent review
- Participate in reviews of utilization by line of business and market
- Report to committees and participate in policy and process improvement
- Support care management and care coordination for members and improve outcomes