Medical Director (Utilization Review
Company: BMC HealthNet Plan
Posted on: February 25, 2021
Reporting to the Chief Clinical Officer (CCO), the Medical
Director, Utilization Review will support the staff of the Office
of Clinical Affairs in the medical oversight of prior
authorizations, durable medical equipment and in-patient reviews.
The position oversees the physicians who conduct medical reviews
and would also participate in, credentialing, appeals and
grievances and medical policy. In addition to leading the training
and mentoring of the physician reviewer program, the medical
director will support the CCO and Office of Clinical Affairs in
developing and maintaining relationships with governmental
organizations, regulatory groups, healthcare providers, and other
external stakeholders in all matters related to medical management.
Key Functions/Responsibilities: Administrative
--- Oversight of the utilization review operations including
appeals and grievances
--- Leads and mentors the physician reviewers and the physician
review training program
--- Supports the Office of Clinical Affairs in developing and
supporting clinical initiatives to support department utilization
--- Supports the physician reviewer training and performance
management and maintains high quality reviews
--- Monitors and leads the physician peer to peer review process in
a collaborative manner with hospital physicians, medical directors,
primary care physicians and nurse case managers in daily
--- Utilizes productivity and outcome dashboards to identify
opportunity areas and develops continuous improvement activities
--- Participates in and chairs clinical committees as assigned by
--- Collaborates directly with the VP and Director of UM to create
efficient, effective and high quality medical review processes.
--- Clinical lead in developing and implementing evidenced based
clinical policies and practices
--- Participate in the development and maintenance of an effective
medical policy program.
--- Assist in the review of utilization data to identify variances
in patterns and provide feedback and education to staff and
--- Participate in the development, implementation and revision of
the clinical care standards and practice guidelines ensuring
compliance with nationally accepted quality standards
--- Participates in the credentialing committee and collaborates
with the leadership of UM to evaluate the performance of UM vendors
on an on-going manner.
--- Assure meeting state, federal and accreditation
--- Participate in the development, implementation, and revision of
corporate level initiatives.
--- Collaborate with market/product leaders to help define market
--- Participate in the evaluation and investigations of cases
suspected of fraud, abuse, and quality of care concerns
--- Monitors appropriate care and services through continuum among
hospitals, skilled nursing facilities and home care to ensure
quality, cost-efficiency and continuity of care. Clinical
--- Conducts review of prior authorizations, concurrent reviews,
retrospective reviews and appeals to ensure members receive
appropriate and medically necessary care in the most cost-effective
--- Conduct peer to peer collaboration with hospital physicians,
medical directors, primary care physicians and nurse case managers
as required during the review process.
--- Assures clinical expertise needed to support BMC HP is
available to perform reviews. --- Direct supervision of full time,
part time and per diem physician reviewers .
Qualifications: Education: --- Graduate as a Medical Doctor from an
accredited college of medicine is required. --- Current board
certification in ABMS or AOA specialty
--- Active, unrestricted physician state license
--- Current unrestricted license as an MD in the Commonwealth of
Massachusetts is preferred. Experience: --- Utilization coverage
--- Applying evidence-based medicine (EBM) and managed care
--- Referencing and applying drug compendia and evidence based
medicine information systems
--- 5+ years clinical practice
--- Clinical experience in both adult and pediatric population
preferred. Competencies, Skills, and Attributes: --- Excellent
demonstrated clinical skills and knowledge.
--- Excellent written and verbal communication skills.
--- Comprehensive knowledge of accrediting organizations such as
--- Comprehensive knowledge of InterQual protocols, HEDIS, and
other quality measures.
--- Knowledge of Medicare and federal/state Medicaid regulations,
guidelines, and standards.
--- Proven leadership skills and relationship building.
--- Demonstrated ability to lead a team.
--- Demonstrated knowledge of managed care principles and
--- Ability to work independently with intermittent
--- Adhere to appropriate turn-around-times and deadlines while
maintain results of high quality and reliability.
--- Administrative experience preferred --- Ability to travel to
locations within New Hampshire and Massachusetts. --- Regular and
reliable attendance is an essential function of the position.
Keywords: BMC HealthNet Plan, Boston , Medical Director (Utilization Review, Executive , Boston, Massachusetts
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