Medical Director Utilization Management

The Medical Director, Utilization Management, provides organizational leadership in the operational areas of appeals, utilization review, quality improvement, and related policy and practice initiatives in collaboration with the Corporate Medical Director(s), Utilization Management, and the Vice President, Medical Affairs. The following responsibilities are regarding enrollees with medical conditions and their providers:

+ Identifying and implementing evidence-based practice guidelines throughout the provider network.
+ Overseeing the quality of clinical care for network and non-network providers.
+ Engaging the provider network in Continuous Quality Improvement through the diffusion of practice standards and an internal quality assurance program that measures network provider performance against high-quality standards, especially the HEDIS program’s performance standards.
+ Ensuring a high-performing Medical Management system that adheres to the terms of contracts a...