PURPOSE AND SCOPE:
Supports Gold Kidney Health Plan's mission, vision, core values, and customer service philosophy. Adheres to the Gold Kidney Health Plan Compliance Program, including all CMS, NCQA, HIPAA, state, federal, and organizational requirements.
The Medical Director: Utilization Management provides physician oversight for inpatient and outpatient utilization management activities for Gold Kidney Health Plan's Medicare Advantage Chronic Condition Special Needs Plan (C-SNP). The Medical Director is responsible for making timely medical necessity determinations for prior authorizations, concurrent reviews, retrospective reviews, and appeals utilizing evidence-based clinical guidelines including CMS National Coverage Determinations (NCD), Local Coverage Determinations (LCD), Medicare Coverage Manuals, Medicare Managed Care Manual guidance, MCG Care Guidelines, and approved Gold Kidney Health Plan Medical Policies.
The Medical Director serves as the physician resource for Utilization Management nurses, Appeals & Grievances, Care Management, Provider Services, Claims, and other operational departments to ensure medically appropriate, compliant, and member-focused healthcare decisions.
DUTIES / ACTIVITIES:
Functions as the physician leader for Utilization Management by reviewing complex inpatient and outpatient authorization requests, conducting peer-to-peer discussions, supporting appeals, and ensuring compliance with CMS Medicare Advantage regulations and NCQA Utilization Management standards.
Applies evidence-based medicine to ensure medically necessary services are authorized while promoting quality outcomes, appropriate resource utilization, and continuity of care for members with Chronic Kidney Disease (CKD), End Stage Renal Disease (ESRD), Dialysis, Congestive Heart Failure (CHF), Cardiovascular Disease (CVD), Diabetes, and other chronic conditions.
Works collaboratively with Clinical Services leadership, Utilization Management Nurses, Appeals & Grievances, Case Management, Provider Services, Pharmacy, Claims, and Compliance to improve quality, efficiency, regulatory compliance, and provider satisfaction.
PRINCIPAL RESPONSIBILITIES AND DUTIES
Utilization Management
- Perform physician review of inpatient and outpatient prior authorization requests requiring Medical Director review.
- Review inpatient admissions for medical necessity including Acute Care, Observation, ICU, Skilled Nursing Facility (SNF), Acute Rehabilitation, Long-Term Acute Care Hospital (LTACH), Dialysis, CKD, ESRD, Heart Failure, Cardiovascular Disease, and Diabetes-related services.
- Conduct concurrent review of inpatient hospitalizations to determine continued medical necessity.
- Perform retrospective medical necessity reviews as required.
- Review clinical documentation submitted by providers to support authorization requests.
- Ensure all determinations are made within CMS-required turnaround times.
Medical Necessity Determinations
- Apply evidence-based clinical criteria including:
- CMS National Coverage Determinations (NCD)
- CMS Local Coverage Determinations (LCD)
- Medicare Benefit Policy Manual
- Medicare Managed Care Manual
- MCG Care Guidelines
- Gold Kidney Health Plan Medical Policies
- Applicable specialty society guidelines
- Ensure medical decisions are clinically appropriate, consistent, and supported by documentation.
Peer-to-Peer Reviews
- Conduct physician-to-physician peer-to-peer discussions with requesting providers.
- Review additional clinical information presented during peer-to-peer conversations.
- Modify medical determinations when supported by additional clinical evidence.
- Document peer-to-peer discussions in accordance with CMS and NCQA standards.
Appeals and Reconsiderations
- Perform physician review of standard and expedited appeals.
- Review organization determinations and reconsiderations.
- Assist with Independent Review Entity (IRE) cases as requested.
- Provide clinical support for Appeals & Grievances staff.
- Ensure appeal decisions comply with CMS regulations and required timeframes.
Clinical Documentation
- Document all medical necessity determinations with complete clinical rationale.
- Include applicable NCD, LCD, MCG, or Plan Medical Policy references supporting decisions.
- Ensure documentation meets CMS, NCQA, and regulatory requirements.
- Maintain complete physician documentation within the utilization management system.
Medical Policy
- Assist in the development, review, revision, and implementation of Medical Policies.
- Recommend updates based on CMS policy changes, clinical evidence, and nationally recognized guidelines.
- Support implementation of new CMS regulations affecting utilization management.
Quality Improvement
- Participate in Utilization Management quality improvement initiatives.
- Review denial trends and physician variation.
- Monitor medical necessity decision consistency.
- Support initiatives to improve turnaround times and provider satisfaction.
- Promote evidence-based clinical practice throughout the organization.
Clinical Leadership
- Serve as physician consultant to Utilization Management Nurses and Clinical Services staff.
- Provide clinical education regarding medical necessity criteria.
- Participate in interdisciplinary case discussions for complex members.
- Collaborate with Case Management and Care Coordination teams to ensure appropriate transitions of care.
Committee Participation
- Participate on the Utilization Management Committee.
- Participate on the Quality Improvement Committee.
- Participate on the Appeals Committee.
- Participate on the Pharmacy & Therapeutics Committee as needed.
- Participate in Medical Policy review meetings.
Regulatory Compliance
- Ensure all utilization management activities comply with:
- CMS Medicare Advantage regulations
- Medicare Managed Care Manual
- Medicare Benefit Policy Manual
- NCQA Utilization Management Standards
- HIPAA
- State regulatory requirements
- Participate in CMS audits, NCQA accreditation reviews, and regulatory audits.
- Assist in responding to CMS audit requests related to utilization management decisions.
Collaboration
- Collaborate with Provider Services regarding complex authorization issues.
- Work with Claims on medical necessity questions involving claim adjudication.
- Partner with Appeals & Grievances to ensure timely resolution of clinical appeals.
- Support Care Management regarding complex clinical cases.
- Collaborate with Compliance and Quality departments on regulatory initiatives.
PHYSICAL DEMANDS AND WORKING CONDITIONS:
The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION: Board Certified Medical Physician (MD) required in general/family practice or internal medicine, nephrology specialist preferred, with an unrestricted license. Board Certification in a specialty (nephrology preferred). Graduate business degree a plus (MBA, MMM, MPH, etc.). Willingness and ability to obtain licensure in multiple states.
EXPERIENCE AND REQUIRED SKILLS:
- Minimum 5 years post-residency experience in the clinical practice of medicine, preferably with management experience.
- Previous experience in Medicare Advantage managed care and Medicaid programs is required;
- Previous experience with accountability for UM standards for NCQA, URAC or general accreditation standards for managed care organizations;
- 2 years previous Medical Director;
- 3 years Utilization/Quality Program Management;
- Minimum 5 years clinical practice;
- Excellent analytical and leadership skills;
- Proficient with MS Word, Excel, PowerPoint, and computer user interfaces;
- Excellent organizational, interpersonal, time management, and communication skills;
- Strong conflict resolution and independent decision making skills;
- Expert project management ability;
- Strong influencing, negotiation, and analytical skills;
- Knowledge of principles of Quality and Care Management;
- organized and detail oriented with a strong bias for follow-up and problem resolution; and
- Proven ability to be a team player.
RELATIONSHIPS:
Internal Contacts: GKHP management, GKHP management, Care Navigation & Care Management, Quality Management, C-SNP plan management and others.
External Contacts: All levels of GKHP customers including patients, patient caregiver/family members, doctors, nurses, other health care professionals, external vendors/suppliers, accreditation and regulatory entities.
Review and comply with the Code of Business Conduct and all relevant Company and Division policies and procedures, and local, state, and Federal laws and regulations.
Ensure that employees understand and comply with the Code of Business Conduct and all-relevant Company and Division policies and procedures, and local, state, and Federal laws and regulations, and establish effective internal systems and controls to promote such compliance.
The duties listed in this job description are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to the position.
