This is an exceptional opportunity to do Utilization Management
and drive innovative work around better patient outcomes for our
top tier client - a Fortune Top 50 Company.
This position will be supporting our Commercial Business of our
Responsible for the administration of medical services for
company health plans including the overall medical policies of the
business unit to ensure the appropriate and most cost effective
medical care is received and for the day-to-day management of
medical management staff.
Primary duties may include, but are not limited to:
· Interprets existing policies and develops new policies based
on changes in the healthcare or medical arena.
· Leads, develops, directs and implements clinical and
non-clinical activities that impact health care quality cost and
· Identifies and develops opportunities for innovation to
increase effectiveness and quality.
· Serves as a resource and consultant to other areas of the
company, may chair or serve on company committees, may be required
to represent the company to external entities and/or serve on
external committees, conduct peer clinical and/ or appeal case
reviews and peer to peer clinical reviews with attending physicians
or other ordering providers to discuss review determinations,
provides guidance for clinical operational aspects of the
· Supports the medical management staff ensuring timely and
consistent responses to members and providers.
Will review specialty cases with a focus on reducing
Cardiology Board Certification required.
Must possess an active unrestricted medical license to practice
medicine in the state of residence.
5+ years of clinical experience
Utilization management experience particularly with Appeals
Previous Managed care experience is a plus
Requires strong oral, written and interpersonal communication
skills, problem-solving skills
Contact information :