This job is archived
NEW Regional Director of Utilization Management - Miami Florida (Come to office 2 days per week)*
Tyler, Texas, United States
Contact Details:
Register to View

Job Summary

Occupation Physician
Specialty Medical Director
Degree Required MD/DO
Position Type Permanent/Full-Time
Work Environment Corporate/Non-Clinical
Location Miami, Florida, United States
Visa Sponsorship No

Job Description

Last Update: 2/19/19
[Register to View] alt="Miami">

The Regional Director of Utilization Management will do clinical medical necessity reviews for our affiliate and employed clinician practices. The RDUM is accountable for orientation, training, coaching and mentoring the Medical Directors. They serve as a physician advisor to the utilization management and care coordination nursing department responsible for clinical process. They are accountable for monitoring market clinical metrics and giving guidance to the Utilization Management clinical team for improvement.

Provide physician review services for utilization management, quality management, and conduct peer to peer reviews

· Develop, maintain and assure compliance with physician review policies and procedures (including timeliness) for utilization management and support case management. · Support collaborative relationships with physicians, large provider groups, hospitals, other facilities and ancillary providers.

· Work closely with market medical directors to assure members are at the right level of care

· Identify potentially unnecessary services and care delivery settings, and recommend alternatives if appropriate by analyzing clinical protocols.

· Examine clinical programs information to identify members for specific case management and/or disease management activities or interventions by utilizing established screening criteria.

· Conduct medical necessity reviews for acute and post-acute initial admission reviews, DME, Home Health continued stay, Skilled Nursing continued stay reviews and post-discharge and discharge planning with clinical staff and peers

· Lead Clinical Round Discussion and educate nursing staff on specific conditions and disease processes

· Support the roll out of clinical initiatives in the local markets through work with the local market physician teams and care coaches

Role Requirements:

· A current and unrestricted Florida medical license and willing to obtain license, as required, for various states in region of assignment

· MD or DO degree

· Board Certified in an approved ABMS Medical Specialty

· Five years clinical patient facing experience – post residency

· Excellent communication skills

· Technical ability with Microsoft Applications and other computer based programs

· Experience working with and/or directing clinical nursing personnel

Preferred Education, Experience & Skills

· Health Plan experience

· Previous Medicare Advantage/Medicare/Medicaid experience

· Previous experience leading teams focusing on utilization management, discharge planning and/or home health or rehab

· Medical management experience, working with managed care clinics, health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.

· Process-oriented, evidence-based and scientifically-inclined, consistent, enjoys being a part of a team, thoughtful and has a thirst for continuous education and development

· Additional Education: BSN or Bachelor’s degree in a related field

· Previous experience in utilization management within managed care industry

· Strong working knowledge of Excel

· Previous experience in Front End Review, SNF, LTAC, DME or Home Health

Reporting Relationships:

· This role reports to the VP in the Utilization Management Department under the leadership of the Care Delivery Organization Shared Service Vice President.

  • 100% NON CLINICAL

  • 100% Medicare Advantage patient base

  • $200,000 to $250,000 Base Salary

  • (Experience based)

  • Starting bonus

  • Paid CME

  • Full Benefits including 401K match and Paid family healthcare