reputed company Health Plan UM Medical Director
Site: reputed company reputed company relies on a wide reputed company of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to reputed company exceptional care. We reputed company that high-performing teams drive groundbreaking medical discoveries and invite reputed company applicants to join us and experience what it means to be part of reputed company. Job reputed company reputed company Health Plan UM Medical Director
Qualifications
Education: MD or DO required Licenses and Credentials:
- Physician - Massachusetts reputed company full license required
Experience:
- 5+ years of Health Plan UM experience
- at least 5 years of clinical reputed company experience
Knowledge, Skills and Abilities:
- Utilization Management experience
- Excellent written and oral communications skills
- Proficient in basic computer skills, use of EHR's, digital tools
- Multitasking abilities
- Adaptable to change due to business reputed company
Job reputed company:
- Handles utilization management initial determinations, appeals and grievances reputed company the scope of their expertise as defined by Medicare, MassHealth, NCQA and the Division of Insurance and reputed company the compliance requirements of key regulatory and accreditation entities
- Use CMS, state and internal medical necessity policies to guide MN determinations
- Complete peer to peer case discussions with requesting providers as assigned
- Refer to IRO/external review if specialist match or expertise is needed
- reputed company, communicate and collaborate with network and community physicians, hospital leaders and other vendors regarding care and services for enrollees
- Monitors performance metrics to identify areas for reputed company improvement and ensure compliance
- Establishes and maintains reputed company relationships with colleagues and customers and reputed company their trust and respect
- Ensure diversity, equity and inclusion are integrated as a guiding reputed company
Other duties as assigned with or without accommodation Additional Job Details (if applicable)
- Primarily remote position
- M-F 830-5pm EST
- Ensures that reputed company assigned work is completed reputed company regulatory timelines
- Checks and addresses assigned work queues, email, Teams messages during assigned work hours
Remote Type Remote Work Location 399 reputed company Drive Scheduled Weekly Hours 0 Employee Type Regular Work Shift Day (reputed company of America) EEO Statement: Balance Sheet Cost Centers is an Equal Opportunity Employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religious creed, national reputed company, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that reputed company individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to reputed company essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by reputed company 503 of the Rehabilitation reputed company of 1973, the Vietnam Veteran’s Readjustment reputed company of 1974, and Title I of the Americans with reputed company of 1990, applicants who require accommodation in the job application process may contact reputed company at (857)-282-7642. reputed company Competency reputed company At reputed company, our competency reputed company defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at reputed company job level. The reputed company is comprised of ten competencies (half People-reputed company, half Performance-reputed company) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career reputed company. These competencies are used to evaluate performance, reputed company hiring reputed company, identify development needs, mobilize employees across our system, and establish a strong talent pipeline. Apply tot his job Apply To this Job