Medical Director - Utilization Management/Care Management, Select Health

Job Description:

Select Health, a regional health plan with over a million members serving all lines of business in Utah, Idaho, Nevada and Colorado, is seeking an experienced Medical Director with expertise in Utilization Management (UM), Care Management (CM) and Health Plan accreditation and other operational and regulatory functions.

The Medical Director of Utilization Management/Care Management, reporting directly to the Chief Medical Officer, leads the UM and CM functions for Select Health from a clinical perspective, ensuring that care services are high quality, appropriate, efficient and in compliance with regulatory and accreditation standards. The role combines oversight of the UM and CM functions with Select Health strategies to ensure members receive coverage and services for high-quality, appropriate, efficient, and cost-effective care.

Essential Functions

• Key Responsibilities 

  • Strategic Leadership: Develop and implement UM and CM strategies using data analytics, technology, and cost-benefit analysis to optimize covered services and care management efforts.  

  • Policy & Process Development: Participate in the creation, revision and enforcement of UM/CM policies, procedures, and protocols to meet regulatory and other accreditation requirements.   

  • Operational Oversight: From a clinical perspective, manage provider reviewers, concurrent reviews, prior authorizations, medical claims reviews, appeals, and grievances and ensure timely and accurate service authorizations consistent with regulatory and accreditation standards.   

  • Efficiency & Innovation: Identify process improvements, redesign workflows, and implement processes including auto-approvals, alternative site criteria evaluation, artificial intelligence solutions and prior authorization efficiency where appropriate to reduce administrative burden. 

  • Pro-Active Care (Value-based Care): Participate in system innovation opportunities such as risk-based contracting, appropriate reduction of prior authorization or other identified opportunities to affect administrative simplification and reduce abrasion for members and providers.  

  • Data & Trend Analysis: Monitor utilization trends, measure productivity metrics, and report on cost savings and quality outcomes across areas of responsibility. 

  • Provider & Vendor Management: Build and maintain strong relationships with such Select Health required vendors and clinical teams necessary to improve care quality and efficiency. 

  • Compliance & Quality: Ensure adherence to state/federal regulations, accreditation standards, and contractual obligations; conduct provider education and training as necessary to facilitate compliance and adherence to quality measures. 

  • Team Leadership: Supervise and mentor UM/CM staff, provide executive-level guidance, and support workforce planning as needed