Utilization Review Medical Director

Job Profile:

This position is the primary for claims, and claims knowledge and experience including demonstrated experience managing claims and claims appeals levels 1-3 are a must in order to be considered for the position.

Performs medical review activities pertaining to utilization review, claims review, quality assurance, and medical review of complex, controversial, or experimental medical services. Engages in peer-to-peer conversations to guide and support delivery of evidence-based care.

Contributes to and supports the corporation’s quality initiatives by planning, communicating, and encouraging team and individual contributions toward quality improvement efforts.

Serves as the chair of Quality Medical Management Committee (QMMC) and other designated committees defined by the organization.

Physician will be engaged in these important projects along with traditional UM activities:

Member of the Medical Leadership Team, the group of Medical Directors and Clinical Leaders at Intermountain Nevada who set the course for Clinical Care and Care Management Initiatives here.

Co-manage several on-going work groups with Specialist groups in Las Vegas to further the causes of managing cost, quality and access for our MG and Affiliate Providers’ patients who will be referred for select specialty care. Examples are those underway working closely with Neurology and Gastroenterology medical groups we are contracted with in the community outside our MG.

Will work with our Care Management Team providing insight around high-risk Care Management programs for our most vulnerable populations we serve.

Will work with our Inpatient Care Team and their Medical Directors on care patterns, admission patterns and level of care.

Skills

Leadership

Interpersonal Communication

Relationship Building

Strategic Planning

People Management

Continual Improvement Process

Workforce Planning

Health Administration

Medical Staff Training

Health Care

Minimum Requirements

• Five years in a professional setting such as hospital, clinic, or home health environment.
• Strong analytical and problem-solving skills.
• Experienced with statistical and fiscal data collection and interpretation.
• Effective communication and interpersonal skills.
• Demonstrated timely documentation and reporting.
• Demonstrated knowledge of case management, utilization management, quality management, discharge planning, and other cost management programs.
• Experienced with oversight in ER, inpatient, and post-acute utilization management, with surgery utilization management a plus.
• Possess a strong progressive and customer-focused approach to building and maintaining customer and provider relations.
• Must have or be eligible to have a current and unrestricted Nevada medical license.
• Minimum of 5 years work experience related to inpatient management, case management, utilization management, quality management, discharge planning, or other cost management.
• Demonstrated experience managing claims and claims appeals levels 1-3.
• Board Certified in Internal Medicine, Family Practice, or other primary care specialty.
• Current Nevada DEA certificate required prior to start date.
• Current Nevada Pharmacy license required prior to start date.
• BLS/ACLS certification

Preferred Qualifications

Additional management degree such as MBA, MPH.