About the job
Job Title: Medical Director – Utilization Management
Location: Remote (8:00-5:00 EST)
UPMC Health Plan Overview
UPMC Health Plan, headquartered in Pittsburgh, Pennsylvania, is among the nation’s fastest growing health plans. It is owned by UPMC, a world-renowned health care provider. As part of an integrated health care delivery and delivery system, UPMC Health Plan is committed to providing its members with better health, more financial security, and the peace of mind they deserve. UPMC Health Plan partners with UPMC and community network providers to produce a combination of knowledge and expertise that provides the highest quality care at the most affordable price. The UPMC Insurance Services Division – which includes UPMC Health Plan, WorkPartners, UPMC for Life, UPMC for You, UPMC for Kids, UPMC Community Health Choices, and Community Care Behavioral Health – offers a full range of group health insurance, Medicare, Special Needs, CHIP, Medical Assistance, behavioral health, employee assistance, and workers' compensation products and services to 3.9 million members. Their local provider network includes UPMC as well as community providers, totaling more than 140 hospitals and more than 29,000 physicians throughout Pennsylvania and parts of Ohio, West Virginia, and Maryland.
For more information about UPMC Health Plan, please visit: www.upmchealthplan.com
Role Summary
Reporting to the Senior Medical Director, the Medical Director, UM, is responsible for ensuring appropriate coverage determinations for the timely delivery of comprehensive, high-quality health care to UPMC Health Plan members. They will oversee adherence to quality and utilization standards through committee delegations and further establish an effective working relationship between UPMC Health Plan and its physicians, hospitals, and other providers.
Responsibilities:
- 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
- Provides expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan
- Remains current with accepted clinical standards of care and professional developments in the areas of quality improvement and utilization management
- Communicates with and educates network providers regarding clinical guidelines, pathways, protocols, and standards related to quality and utilization processes
- Interacts with physicians regarding opportunities to improve compliance with Utilization Management and Quality Improvement policies and procedures
- Contributes to process improvement within Utilization Management department
- Participates in activities to support policy decision making
- Utilizes clinical experience to support departmental review
Benefits Package Summary
UPMC offers a premier benefits package, designed to care for your total well-being – physically, emotionally, and financially – paired with endless opportunities for career advancement and growth. Discover the culture, the teams, and the passions that drive us to make Life Changing Medicine happen.
