Lead utilization management strategy, including oversight of medical necessity determinations and review processes
Own medical policy development, incorporating regulatory updates and care guideline changes
Lead and Partner with the Utilization Management Review Committee
Provide medical oversight, expertise, and leadership to ensure the delivery of cost effective, quality healthcare services to health plan members
Promote positive relations with the local medical community, including periodic consultation with providers, facilities, caregivers, etc.
Review case management data to identify trends, gaps in care, and recommend corrective actions
Provide oversight and direction for staff and provider training and education
Integrate clinical quality and best clinical practices into medical management program development
Evaluate the development of new programs and the continuation of existing programs
Investigate future care management and patient engagement technologies and evaluate their impact on providers’ practices, patient safety, and patient experience

Active, unrestricted Texas (TX) medical license without limitations or sanctions
Doctor of Medicine (MD) with 8+ years of clinical experience; management experience preferred
Board certification in a specialty recognized by the American Board of Medical Specialties
Experience working within a health insurance plan, with an emphasis on population health
Experience in managed care and utilization management, including performing utilization reviews within a health plan
Strong knowledge of managed care systems, quality improvement, and clinical best practices
Experience with MCG or other clinical guidelines

Competitive salary
Comprehensive health, dental, and vision insurance as well as life and disability
Retirement savings plan with company match
Generous time off/vacation
Professional development opportunities
Flexible and remote work environment

Medical Director – Health Plan

Key skills