Medical Director II, Utilization Management
Job Description A bit about this role: This position interacts with utilization management, clinical management, pharmacy, network management, data analytics, legal, finance as well as other health plan departments. As a Medical Director in Utilization Management, you share responsibility for leadership in the appropriate use of medical services within established quality and evidenced based guidelines as well as executing the essential functions below: Your Responsibilities and Impact will include: Assists in development and maintenance of an efficient UM program to meet the needs of health plan members commensurate with company values. Perform clinical reviews (i.e., part A, B, appeals, quality of care) and conduct peer to peer discussions. Participate in inter-rater reliability activities. Participate in analysis of utilization data and suggest improvement opportunities. Provide appropriate mentoring and leadership to clinical teams as well as develop relationships to support growt