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 client organization.
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 outcomes.
· 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 program.
· Supports the medical management staff ensuring timely and consistent responses to members and providers.
Will review specialty cases with a focus on reducing spending.
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 required
Previous Managed care experience is a plus
Requires strong oral, written and interpersonal communication skills, problem-solving skills