Medical Director, Utilization Management

COMPANY OVERVIEW:

HealthAxis is a prominent provider of core administrative processing system (CAPS) technology, business process as a service (BPaaS), and business process outsourcing (BPO) capabilities to healthcare payers, risk-bearing providers, and third-party administrators. We are transforming the way healthcare is administered by providing innovative technology and services that uniquely solve critical healthcare payer challenges negatively impacting member and provider experiences.

We live and work with purpose, care about others, act with integrity, communicate with transparency, and don’t take ourselves too seriously.

We're not just about business – we're about people. Our commitment to a people-first approach shapes everything we do, from collaborating as a team to serving our valued clients. We believe that creating a vibrant and human-centric environment can inspire engagement, empower our team members, and ignite a sense of purpose in all that we accomplish.

PURPOSE & SCOPE:

The Medical Director of Utilization Management is responsible for working hand-in-hand with senior leaders to provide medical expertise and decision making within the Utilization Management team. This role will be responsible for ensuring that healthcare services are medically necessary, appropriately utilized, and meet the highest standard of quality. Adhere to standard Federal, State and/or CMS compliant medical policies within the organization. This role involves reviewing clinical cases, providing medical expertise, and collaborating with various stakeholders to ensure efficient and effective healthcare delivery. All departmental workflows and document retention must be adhered to by the Medical Director. At times, peer to peer phone and/or teams calls may be required based upon business and contractual needs.

PRINCIPAL RESPONSIBILITIES AND DUTIES:

• Assists in development and maintaining an efficient UM program to meet the needs of the health plan members and commensurate with company values.

• Educates primary care physicians regarding systems, structures, processes and outcomes necessary for assurance of regulatory compliance related to market activities.

• Develops strategies for improving all aspects of market performance including RAPS, membership, and medical management.

• Participates in case reviews and medical necessity determination.

• Serve as a resource for clinical staff, offering guidance on complex cases and medical necessity.

• Conducts post service reviews issued for medical necessity and benefits determination coding.

• Maintains accurate and thorough documentation of activities and decisions.

• Analyzes aggregate data and reports to primary care physician.

• Serves as the liaison between physicians and health plan Medical Directors.

• Performs secondary review when prior authorization, initial and concurrent reviews do not meet medical necessity criteria or level of care appropriateness.

• Participates in the Grievance and Appeal review process to provide recommendations.

• Utilize clinical expertise to identify the salient points within a case review.

• Identify process improvements opportunities and inefficiencies.

• Interact with external physicians as needed – through secure messaging, text, and potential phone calls.

• Opportunity to be involved in additional responsibilities such as special projects, focus groups, new Medical Director training, or organizational committees.

• Collaborate with management and operations team members to propose strategic, operational, and technological solutions for improving quality.

• Other duties as assigned.

EDUCATION, EXPERIENCE AND REQUIRED SKILLS:

• Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) degree.

• Preferably, Board Certified Family Practitioner or Internal Medical Specialist.

• Unrestricted licensed in at least one state within the United States.

• 5+ years of clinical practice experience.

• 2+ years of experience in utilization management activities.

• Proficiency with Microsoft Office applications.

• M.D or D.O and five (5) years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.

• Board Certified in an American Board of Medical Specialties Board, and an active, unrestricted license to practice medicine in a state or territory of the United States.

• Previous experience with administrative oversight of the medical function of an insurance (or related) company.

• Previous experience leading a team of professionals.

• A strong perspective on how to increase operational excellence and automation through process improvement and technology partnerships.

• Strong interpersonal skills, with the ability to regularly interact with various client departments/project teams.

• An ability to balance critical thinking with hands-on execution. Forward-thinking strategic leader.

• Results-driven. Ability to work in a fast-paced and changing environment and react professionally under pressure.

• Self-starter with strong organizational skills. Excellent oral and written communication skills.