Albuquerque, New mexico
Medical Director - Utilization Management Job Opening in Albuquerque, New mexico - New Mexico Health Connections
Medical Director, Utilization Management
New Mexico Health Connections (NMHC) is a physician-led health plan committed to removing barriers to care and keeping New Mexicans healthy.
Our mission: keeping our members healthy, lowering premium costs, and delivering appropriate levels of care at the right time to keep our members out of the hospital unless they need to be there.
We recognize that our members do best through strong relationships with their healthcare providers and that a strong network of primary care providers is critical to ensuring the good health of our members, and we take steps to ensure that our members are established with primary care providers.
We sell health plans on and off the exchange to individuals, small businesses, and large employer groups throughout New Mexico as well as administrative service only arrangements.
Overview
Reporting to the Senior Medical Director and providing leadership across all Medical Management areas, the Medical Director of Utilization Management drives programmatic approaches to utilization management and quality in member care and the development of innovative solutions to streamline processes and improve performance throughout the Company?s provider network.
Responsibilities
Works closely with Senior Medical Director and Utilization Management (UM) clinical staff to ensure that requested services are medically necessary, are performed in the appropriate setting, and are consistent with medical practice standards.
Works closely with Medical Management team and both in-house and outsourced UM personnel to deliver exceptional and timely service to members and providers, including identifying programmatic resource needs and strategies for overall UM programmatic excellence.
Oversees ongoing development and monitoring of the UM program.
Oversees and monitors UM requirements to maintain National Committee for Quality Assurance (NCQA) accreditation status.
Oversees medical policy related to UM activities and serves as chair of the Company?s New Technology Committee.
Serves on Credentialing Committee and acts as co-chair of the Integrated Clinical Management Committee.
Oversees and monitors the Company?s published list of services requiring prior authorization, continuously working to reduce the administrative burden experienced by network providers in fulfilling the prior authorization process requirements.
Works closely with Medical Directors and the departments of Provider Services, Analytics, and Quality to develop and support value-based contracts and innovative programs.
Conducts medical necessity reviews on medical and behavioral service requests, making determinations in compliance with NCQA standards and Office of the Superintendent of Insurance (OSI) and Centers for Medicare & Medicaid Services (CMS) requirements.
Works closely with the Company?s Behavioral Health Consultant to identify programmatic resource needs in behavioral health, to evaluate and support NCQA behavioral health requirements, to evaluate behavioral health service requests, and to develop and support innovative behavioral health programs to improve the coordination and care of members.
Conducts reviews addressing care requests for members from out-of-network providers, including Centers of Excellence.
Supports Company?s identification and use of optimized medical necessity criteria set(s).
Responds to provider requests for peer-to-peer discussions in a timely and proactive manner, partnering with clinicians to support optimal member care.
Supports access to and rostering of additional specialist clinicians for initial determinations and appeals, including behavioral health specialists.
Works closely with Company Director of Pharmacy and Medical Directors to oversee appropriate utilization of the pharmacy benefit, collaborating as well with the contracted Pharmacy Benefit Manager.
Operates as a key participant in member and provider appeals processes.
Working with Compliance leadership and staff, ensures integrity of appeals process according to established standards and regulatory oversight.
Identifies trends that serve to direct UM programmatic improvement activities.
Reports specific quality-of-care issues to appropriate Medical Management team members.
Identifies network provider opportunities for transition to delegated UM arrangements and supports ongoing monitoring of delegated UM activities.
Works with Provider Services to identify contracting opportunities and provider engagement as they arise through authorization requests.
Participates in Company multidisciplinary care team meetings and committee meetings as appropriate.
Works with Medical Management team to assess provider satisfaction with prior authorization process.
Works closely with Company network provider leaders to ensure active and meaningful engagement around Company medical policy developments and their impact.
Supports Company efforts to optimize member benefit and plan product structures to result in overall improved outcomes while maintaining affordability.
Identifies and implements other strategies that ensure members have accessible, affordable, quality care, and that the Company remains in good financial health.
Other duties as assigned.
Qualifications
Unrestricted medical license in the state of New Mexico required.
At least 8 years of broad medical leadership experience, preferably with health insurance organization(s) with oversight of utilization management.
Ability to drive program development and meet deadlines.
Ability to communicate with and influence a variety of constituents.
Ability to identify and expediently implement program changes as needed.
Experience in the New Mexico health insurance market preferred.
Energized by, and compatible with, a start-up setting, including comfort with rapidly evolving organizational needs and priorities.
Physical Demands
Continuous sitting for approximately 70 percent of the work day.
Continuous use of arms, hands, and fingers to operate keyboard, computer, mouse, scanner, printer, copier, fax, and other office equipment.
Continuous use of vision and hearing.
Frequent lifting of up to 15 pounds, from floor level to waist height.
Frequent bending, twisting, and reaching.
Occasional kneeling.
Occasional walking and standing throughout the day, which may include extended continuous standing for copying and faxing tasks.
Occasional lifting of up to 30 pounds, from floor level to waist height.
Work Environment
Normal office conditions in an indoor environment.
NMHC is an Equal Employment Opportunity Employer. Salary is dependent on experience. Submit cover letter and resume to HR .
Job Type: Full-time
Job Location:
Albuquerque, NM
Required education:
Doctorate
Required experience:
broad medical leadership: 8 years
Required license or certification:
Unrestricted Medical License for state of New Mexico
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