COVID-19 Vaccination Information

Across UPMC, our guiding principle is to always prioritize the safety of our employees, patients, and members. UPMC believes that vaccination is important, helps protect all, and advocates that everyone who can be vaccinated should be vaccinated.

UPMC complies with all governmental requirements related to local, state, and federal COVID-19 vaccination for employment. The Jan. 13 Supreme Court of the United States decision that the Centers for Medicare & Medicaid Services federal COVID-19 vaccine mandate will move forward requires UPMC to ensure employees either get vaccinated or receive a requested medical or religious exemption.

If you are not yet vaccinated, we urge you to get a vaccine now. You can schedule your COVID-19 vaccination through UPMC or visit a non-UPMC provider or UPMC Urgent Care location.

Proof of vaccination is not required upon hire; however, employees will be responsible for ensuring post-hire compliance by getting vaccinated or requesting a medical or religious exemption.

For more information about UPMC’s response to COVID-19, please visit UPMC.com/coronavirus.

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   Current UPMC employees must apply in HR Direct

Utilization Review Medical Director

  • Job ID: 22000384
  • Status:
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: Corporate Revenue Cycle
  • Department: Hospital Division Admin
  • Location: Work From Home
  • Union Position: No
  • Salary Range: $0 / hour

Description

Join the Hospital Division Administration Team today as a Utilization Review Medical Director! There are full time, part time, and casual opportunities available. Apply today! 

As the Medical Director of the UPMC Health System Care Management, you will be responsible for assisting in development and implementation of consistent policies and procedures for the UPMC Health System care management (CM) functions including:  authorization for services, level of care determinations, retrospective clinical denial management and reporting. This position is responsible for implementation of utilization care management initiatives with goals of quality and financial outcomes. The medical director represents UPMC care management to senior leadership, physicians, hospital providers and payors. 

Responsibilities:

  • Advise, assist and educate treating physicians, hospital care managers, senior medical management, administration and all others involved in the delivery of timely, appropriate and cost-effective care.
  • Conduct verbal and written review and appeal of denied or downgraded coverage determinations made by managed care/commercial payors.  Timely concurrent and retrospective appeals are a priority.
  • Facilitate communication between managed care/commercial payors and providers regarding benefit coverage issues, utilization review and quality assurance processes.
  • Serve as a resource to the Care Management staff on medical necessity, level of care, denial management, resource utilization and payor requirements
  • Promote payor and provider adherence to Joint Commission, state regulations, and all other applicable regulatory standards.
  • Promote hospital adherence to ensure compliance with government and commercial payors' policies regarding level of care and medical necessity.
  • Discuss and educate treating physicians regarding alternative courses of action or modification to the treatment plan, including but not limited to, appropriate documentation of the plan of care, to resolve utilization issues.
  • Document clearly and concisely, following hospital guidelines, all communications, interactions, interventions and outcomes of medical director work in care management documentation system.
  • Maintain high ethical patient-centric standards
  • Review retrospective denials and third-party audit denials that are determined to require write-off by corporate CM.  Take active role in analyzing corporate CM reports and identifying opportunities for improvement, utilization trends within each institution and system-wide, and propose potential solutions to executive management to address issues as appropriate.
  • Review inpatient and outpatient denial data and assist in the development of denial prevention interventions.
  • Provide education on utilization management topics to the hospital medical staff.
  • Performs in accordance with system-wide competencies/behaviors.
  • Performs other duties as assigned.

Qualifications

Education: 

  • MD or DO required. Masters level degree in business and/or health care administration (i.e. MBA, MHA, MMM) preferred.

Experience Required: 

  • Minimum 5 years in clinical practice in hospital setting. Administrative experience preferred.


Skills Required: 

  • Strong clinical and problem-solving skills; excellent communication, interpersonal and negotiation skills; high tolerance for complex, ambiguous and ever-changing environment; demonstrated leadership capabilities and analytical skills; positive and constructive relationships.


Skills Preferred:
1) Familiar with structure and practices of managed care organizations in utilization review and contract management
2) Understands Joint Commission guidelines as pertains to utilization management and reviews
3) Familiar with CMS guidelines regarding medical necessity and compliance
4) Working knowledge of InterQual and Milliman guidelines and understands their appropriate application and limitations
5) Understands CMS reimbursement rules including last covered day and how they relate to the clinical management of the patient
6) Understands coding principles and impact of documentation on reimbursement
7) Experience with computer systems (i.e. Cerner, Epic, Canopy and/or HealthPlaNET)
8) Experience successfully conducting physician-to-physician discussions (peer to peer) with payers strongly preferred

 

Licenses and Certifications Notes

  • Licensure/Certification: Unrestricted license to practice medicine in the Commonwealth of Pennsylvania and/or where applicable. Board Certified. Member in good standing with the medical staff of the UPMC Health System.

 

Licenses and Certifications

  • Doctor of Medicine (MD) OR Doctor of Osteopathic Medicine (DO) 

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Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct

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