Job Description

Job Title: Medical Director - Utilization Management
Job ID: 709915
Status: Full-Time
Regular/Temporary: Management
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: Medical Director Service
Location: 600 Grant St, Pittsburgh PA 15219

Description

UPMC is actively seeking a Medical Director – Utilization Management to support our UPMC Health Plan in Pittsburgh, Pennsylvania!

It will be important that this individual has a Doctor of Medicine or Doctor of Osteopathy from an accredited school. They should have a minimum five years of clinical experience. As well as an active Pennsylvania medical license without restrictions, a Board Certification and enrollment in MOC in a Board accredited by ABMS or AOA is highly preferred.


The Medical Director is responsible for assuring physician commitment and delivery of comprehensive high-quality health care to UPMC Health Plan members. Oversees adherence to quality and utilization standards through committee delegations, and further establishes an effective working relationship between UPMC Health Plan's Network and its physicians, hospitals and other providers.

Responsibilities:

  • Act as first level physician reviewer for all cases referred by the Quality Improvement and Care Management Departments.
  • Actively participates in the daily utilization management and quality improvement review processes, including concurrent, prospective and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns.
  • Communicate and educate network providers regarding clinical guidelines, pathways, protocols, and standards related to quality and utilization processes.
  • Daily activities support adherence to quality and utilization standards, and establish an effective working relationship between UPMC Health Plan's Network and its physicians, hospitals and other providers.
  • Daily interventions support implementation of the Health Plan's Quality Improvement and Care Management Programs.
  • Interacts with physicians regarding opportunities to improve member satisfaction and compliance with Utilization Management and Quality Improvement policies and procedures.
  • Keep current with accepted standards and professional developments in the areas of quality improvement and utilization management.
  • Physicians must devote sufficient time to the CHC-MCO to provide timely medical decisions, including after-hours consultation, as needed
  • Provide expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan.
  • Provide leadership and direction in meeting Quality Improvement and Care Management goals directed at improvements in member health status outcomes and established business strategies.
  • Provide leadership direction for provider credentialing processes.
  • Represent the Health Plan in external accreditation and certification activities.
  • Responsible for reporting the communication of reportable communicable diseases in accordance with statute.
  • Work with the DOH State and District Office Epidemiologists in partnership with the designated county/municipal health department staff to appropriately report reportable conditions in accordance with 28 Pa. Code 27.1 et seq.

Qualifications

  • Doctor of Medicine or Doctor of Osteopathy from an accredited school.
  • Minimum of five years of clinical experience is highly preferred.
  • Active Pennsylvania medical license without restrictions highly preferred.
  • Board Certification and enrollment in MOC in a Board accredited by ABMS or AOA highly preferred.


Licensure, Certifications, and Clearances:

  • Doctor of Osteopathy or Medical Doctor

Salary Range: $0 to $0

Union Position: No

At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!

QUALITY & SAFETY
DIGNITY & RESPECT
CARING & LISTENING
RESPONSIBILITY & INTEGRITY
EXCELLENCE & INNOVATION

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