Medical Director,Utilization Management

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Company: Oak Street Health 

Title: Medical Director, Utilization Management

Location: Treehouse

Role Description:

The Medical Director, Utilization Management is responsible for overseeing the utilization management (UM) processes to ensure the delivery of high-quality, cost-effective healthcare services. This role involves managing the review of medical necessity, appropriateness of care, and the coordination of healthcare services. The Medical Director, UM will lead and manage a team of UM professionals, providing guidance, support, and professional development opportunities to optimize team performance. Additionally, the Medical Director will collaborate with various departments, healthcare providers, and external stakeholders to enhance healthcare delivery and improve patient outcomes.

Core Responsibilities:

Leadership and Management:

• Lead and manage the Utilization Management team, providing guidance, training, and support.

• Support recruiting, hiring, and retaining skilled UM clinical staff, fostering a collaborative and high-performance work environment.

• Conduct regular performance evaluations, offering feedback, coaching, and professional development opportunities.

• Develop and implement UM policies and procedures in compliance with regulatory requirements and industry standards in conjunction with other UM Leadership.

• Monitor and evaluate the performance of the UM team, ensuring efficiency and effectiveness in all UM activities.

Utilization Review:

• Conduct and oversee clinical reviews of medical records to determine the medical necessity and appropriateness of healthcare services.

• Ensure timely and accurate review of prior authorizations, concurrent reviews, and retrospective reviews.

• Collaborate with healthcare providers to facilitate appropriate utilization of healthcare resources.

Quality Assurance and Improvement:

• Develop and implement quality assurance programs to monitor and improve UM processes.

• Analyze UM data and metrics to identify trends, gaps, and areas for improvement.

• Implement evidence-based practices and clinical guidelines to enhance patient care and outcomes.

Compliance and Regulation:

• Ensure compliance with all federal, state, and local regulations related to utilization management.

• Stay current with changes in healthcare regulations and standards affecting UM practices.

• Prepare and present reports to regulatory agencies, accrediting bodies, and internal stakeholders as required

Collaboration and Communication:

• Work closely with other departments, including Transitions, Case Management, and Care Teams, to ensure coordinated and integrated care.

• Communicate effectively with healthcare providers, patients, and other stakeholders regarding UM decisions and policies.

• Serve as a clinical resource and advisor to the UM team and other departments.

• Other duties as assigned.

What are we looking for?

An ideal candidate will satisfy the following;

• At least 2 years experience providing Utilization Management services to a Medicare and/or Medicaid line of business

• Excellent verbal and written communication skills

• A current, clinical, unrestricted license to practice medicine in the United States. (NCQA Standard)

• Prior clinical leadership or supervision experience is preferred