Job Description

Job Title: Director, Medical Management
Job ID: 50979010
Status: Full-Time
Regular/Temporary: Management
Hours: 8:00-4:30
Shift: Day Job
Facility: UPMC Health Plan
Department: UM Clin Ops
Location: 600 Grant St, Pittsburgh PA 15219

Description

Purpose:
The Director, Medical Management will be responsible for directing and managing the medical management activities of the UPMC Health Plan, for all products.

Responsibilities:

  • Manage activities relating to the monitoring of utilization management of resources for the network hospitals. 
  • Ensure that the monitoring and education process is supporting achievement of the targeted utilization management results established by the Health Plan.
  • Participate in the design and implementation of training and development programs.
  • Manage activities and processes related to medical review: on-site review process, telephonic review process and hospital/Health Plan integration processes.  
  • Responsible for approval processes of predetermination, prior authorization, out-of-network, transition of care and selected other reviews.
  • Specify personnel accountability and evaluates performance regularly
  • Function as a liaison between the UPMC Health System and other network facilities to ensure successful utilization management processes.
  • Participate in the development of the departmental strategic business plan to ensure the attainment of the Health Plan's strategic objectives by identifying, recruiting, developing, directing, and evaluating personnel within the department.
  • Manage the authorization data entry process to ensure timeliness, accuracy, validity and established performance.
  • Manage activities relating to special projects for utilization management and resource consumption. Ensure compliance with work plans and goals.
  • Establish and delegate the job duties for all positions
  • Develop the operating budget for the functional area and manages resources appropriately.
  • Manage the timeliness and accuracy of utilization management reporting requirements for regulatory agencies, Department of Welfare, internal executive staff and ad hoc reports as appropriate.
  • Represent Medical Management on internal and external forums and committees, as requested.

Qualifications

  • Bachelor's Degree in Nursing or a closely related field (Master's Degree strongly preferred).
  • Extensive experience with utilization management principles and delivery systems required.
  • Experience with healthcare financing principles, such as payment methodologies required.
  • Proven ability to manage utilization management processes with evidence of meeting established goals and outcomes preferred.
  • Ability to manage staff and resources within established budget guidelines to achieve desired departmental goals preferred.


UPMC is an Equal Opportunity Employer/Disability/Veterans

Salary Range: $0 / hour

Union Position: No

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