Perform all types of utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals
Discuss cases with physician providers (Peer to Peer)
Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests
Collaborate with Case Managers to provide support and guidance on cases needing physician assistance
Meet any established metrics (compliance and accreditation) related to UM review efficiency, timeliness, and quality of review
Participate in ongoing Inter-rater reliability (IRR) audits and any other health plan audits as necessary
As necessary, assist nurses and other staff in understanding the principles behind appropriate utilization review and interpretation and application of benefits and policies
Participate in the development and review of Medical and Pharmacy policies as assigned
Support the organization as a subject matter expert
Perform as lead Medical Director consultant for one sub-category of utilization management, such as commercial or Medicare medical policy
Perform other duties as assigned and needed by the organization

Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine
Board Certification or Board eligibility by American Board of Medical Specialties or equivalent
5+ years of clinical experience
Experience working in a dynamic, fast-paced environment
Experience working both independently and in a team environment
Exceptional verbal and written communication
Physician reviewer or utilization management experience (Preferred)
Primary Care Specialty physician experience (Preferred)

Medical Director – Care Management

Key skills