Purpose:
The Senior Medical Director will have the rare and exciting opportunity to join a senior team recognized as UPMC’s best and brightest leaders.The Senior Medical Director provides executive clinical leadership across Utilization Management, Quality, and Medical Policy functions, ensuring medically appropriate, timely, and compliant decision making that supports high-quality, cost-effective care for Commercial, Medicare, and Medicaid members. This role will provide significant support for Utilization Management (UM) Reviews & Medical Necessity Oversight and UM Process Improvement, Medical Policy and Operational Excellence Support.

Responsibilities:
 

• Provide expedited clinical review and determination of medically urgent and time sensitive cases, including inpatient admissions, continued stays, and high-risk outpatient services, in accordance with CMS, NCQA, state regulatory standards, and Health Plan turnaround time requirements.
• Ensure rapid escalation pathways are followed for medically pressing issues, balancing patient safety, quality of care, and appropriate resource utilization.
• Actively participate in and provide clinical oversight of Utilization Management activities, including prospective, concurrent, and retrospective medical necessity reviews, ensuring timely, evidence-based determinations that are consistent with Health Plan policies, nationally recognized clinical guidelines, and regulatory requirements.
• Lead and contribute to continuous process improvement initiatives within the Utilization Management department, focusing on consistency of determinations, reduction in unwarranted variation, operational efficiency, provider experience, and member outcomes.
• Partner with UM leadership, Quality, Operations, and Analytics teams to identify trends in denials, overturn rates, appeals, and utilization patterns, translating insights into actionable improvements in workflows, training, and policy application.
• Participate in and support medical policy development and governance activities, including review of emerging evidence, assessment of clinical appropriateness, and alignment of UM criteria with regulatory guidance and organizational strategy. Serve as a clinical advisor to policy and utilization decision making committees, ensuring policies reflect current evidence, clinical best practices, and appropriate balance between access, quality, and affordability.
• Serve as a senior clinical decision maker for complex UM cases, including second level reviews, provider appeals, member grievances, and quality of care concerns, exercising sound medical judgment and consistent application of medical policy.
• Assist with the development of a clinical organization which prioritizes the retrieval and intuitive interpretation and evaluation of statistics and medical trends in order to establish aggressive preventative health targets and objectives.
• Serve on physician committees and work with each Health Management program to monitor, assess and ensure the program’s clinical success. Establish best practices for care programs including Diabetes, Asthma, Congestive Heart Failure, End-Stage Renal Disease and Maternity Programs.
• Create progressive physician group and provider education programs; direct concurrent education and communication related to credentialing, UM, and QI. The Senior Medical Director will be responsible for the Technical Assessment Committee (TAC).Establish and implement superior performance standards while maintaining compliance with applicable statutes, rules and regulations, the standards of accrediting bodies and corporate policies and compliance program standards.
• Collaborate with VP, Medical Affairs and to engage all functional areas of the Health Plan from a clinical perspective to develop innovative programs as well as products lines; serving as the primary clinical liaison with Network Services, Strategic and Advisory Services, Finance and Underwriting, Operations, Information Systems, Pharmacy, and Product Development.
• Serve as an integral part in the design and implementation of medical management initiatives such as disease management to improve quality and cost effectiveness of care delivered to Commercial, Medicare and Medicaid members.
• Swiftly respond to challenges and/or opportunities as they arise. Develop and implement innovative programs to act on historical data, identifying new trends, retooling existing approaches, and analyzing the competition.
• Collaborate with physicians to develop clinical programming by accessing and mining clinical data, devising methods to manage populations. Partner with physicians to improve reimbursement model and performance based physician incentive programs.
• Collaborate with Vice President, Medical Affairs, and Health Plan senior leadership in the development of short-term, mid-term, and long-range strategic planning for the Health Plan. Partner with physician leaders, and hospital and business executives to exceed clinical, operating, financial, quality, and market share objectives. Deliver executive level presentations for UPMC senior management and other designated groups.
• Lead the Utilization Management organization, Pod functions, as well as Quality of Care; leading management of 2nd level grievances, guiding and managing the most complex cases, appeals, quality regulatory requirements, credentialing, trouble-shooting and special investigations.
• As an integral member of UPMC Health Plan’s leadership team, serve as a ‘role model’ and ‘health advocate’ within the Western Pennsylvania community, including active participation with UPMC sponsored activities, public events and community outreach programs.
• Provide clinical leadership and support for Quality Improvement program, including study design for NCQA accreditation initiatives, coordination of HEDIS reporting, as well as meeting or exceeding all regulatory requirements. Serve as Clinical Leader for the UPMC for Life Medicare program.
• Identify opportunities to further integrate information systems and departmental interface capabilities, and from a clinical perspective, assist in affecting the ‘phase-in’ of newly acquired OAO interactive software.
• Directly participate in the oversight of the QM Department and the UM Department.
• As a clinical ‘thought leader’ and UPMC Health Plan physician liaison, participate in the creation of opportunities to consult, interact and elicit feedback with the physician community, then act upon this valuable information, raising proactive clinical intervention to unprecedented levels.
• Nurture personal and professional growth/development by attending seminars, workshops, and establishing professional affiliations to keep abreast of latest trends in field of expertise.
• Ensure continuous improvement strategies are established and implemented for Health Management outcomes and processes, encouraging a culture which initiates intensive and persistent case management for members.
• Influence medical cost trend in partnership with network services and medical management team, including development of trend-specific initiatives, provider fee schedule review, and identification of medical management best practices. Create opportunities to integrate pharmaceutical and medical strategy with innovative solutions.
• Interface with UPMC Health System cross-functional and shared resources to further the ’cause’ to create a seamless healthcare patient-flow management process and insurance model.
• Motivate and mentor UPMC Health Plan’s clinical Medical Affairs staff by ‘setting the pace’ and fostering ‘excellence by example’. Assess the overall team, including ongoing recruitment and hiring of talent. Ensure that the organization has the ‘right people’ in the ‘right positions’ and that the organization’s structure is designed to maximize results.
• Collaborate with the VP, Medical Affairs and Chief Medical Officer to develop unique partnerships and differentiated relationships with current and prospective employer groups, consultants and brokers, in order to understand and meet their health and welfare needs.
• Passionately manage UPMC Health Plan’s clinical Medical Affairs organization for Commercial, Medicare and Medicaid lines of business, to include; leading, educating and mentoring Medical Directors, managing all clinical aspects of Medical Management, Quality, Health Management, Utilization Management, Disease Management, Strategic Planning and Policy.