Insurance Utilization Reviewer Jobs in Raleigh, NC

Care with Heart. Work with Purpose.

Volunteers of America National Services (VOANS) is seeking a Medical Director. The Medical Director Provide direction to Senior CommUnity Care related to the medical delivery of care by providers and ensures the delivery of quality health care services. Supports and directs Senior CommUnity Care medically-related committee work. This is a onsite role. Proudly Great Place to Work Certified for 8 consecutive years.

Salary: $248,000-$298,000 (Based on years of Experience)

Location: 5400 S Miami Boulevard, Suite 150, Durham, NC 27703

Schedule: Monday-Friday 8:00 AM-5:00 PM (Every Other Weekend)

The Medical Director objective is to provide direction to Senior CommUnity Care related to the medical delivery of care by providers and ensures the delivery of quality health care services. Supports and directs Senior CommUnity Care medically-related committee work.

Why You'll Love It Here

• Mission-driven work that makes a difference
• Supportive and collaborative leadership
• Strong, team-oriented culture
• Opportunities for career growth and advancement
• Inclusive and purpose-driven environment

What We Offer

• Medical, Dental & Vision Insurance
• 403(b) Retirement Plan with discretionary contribution
• Paid Time Off (Vacation, Holiday & Sick Days)
• Life Insurance & Short-Term Disability
• Employee Assistance Program
• Wellness incentives (earn up to $350)
• Early pay access (up to 50% of earnings)
• Referral bonuses & career scholarships

Key Responsibilities

• Responsible for oversight of delivery of care and clinical outcomes.
• Provides medical guidance and supervision of medical services.
• Provides leadership and medical expertise in the development of medical policies, procedures and guidelines.
• Responsible for the development of Senior CommUnity Care clinical standards and medical practice guidelines and protocols.
• Provides oversight of the QI Plan.
• Reviews all quality of care issues and oversees the development and implementation of quality of care corrective action plans.
• Participates in the oversight, training and education of internal providers and the interdisciplinary team.
• Coordinates performance appraisal of the Internal providers.
• Develops educational and other programs to build the skills of participating providers.
• In conjunction with Contract Manager engages in communication with the provider network.
• Represents Senior CommUnity Care to external agencies, professional groups and regulatory agencies and organizations as required.
• Demonstrates necessary skills and knowledge as outlined in position-specific competency requirements.
• Assumes overall accountability and responsibility for the medical care of the participants at Senior CommUnity Care Program. Oversees the medical service team in the PACE program area to promote quality and outcome goals.
• Monitors PACE medical/clinical staff to assure practice is in compliance with Occupational Safety and Health Administration (OSHA) regulations and agency policies and procedures.
• Participates in the development and implementation of compliance programs. Enforces and promotes compliance with laws and regulations.
• Performs initial and annual competencies on internal providers at the PACE program.
• In conjunction with the Board, Quality Manager, is responsible for QI plan and activities. Reviews data, identifying areas of opportunity for improvement. Engages with development of annual plan and benchmarks. Participates in CMS and Senior CommUnity Care collaboration with Level 2 reporting.
• Participates in Utilization Review inclusive of but not limited to ED visits, hospitalizations, SNF, LTC, AL, and specialty visits. Assesses for areas of opportunity for procedural, operational and/or service delivery changes.
• Oversees CMS diagnostic coding practices at the PACE program.
• Assists with the development of policies and procedures, standards of care. Performs on-going monitoring and evaluation of patient care practice and service delivery. Provides guidance and training to staff regarding medical and quality assurance issues.
• Maintains participants' medical record and fulfills Senior CommUnity Care charting and reporting requirements as they apply to the Medical Director's role.
• Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families.
• Follows all Senior CommUnity Care policies and procedures and Occupational Safety and Health Administration (OSHA) safety guidelines.
• Participates in continuing education classes and any required staff and training meetings. Maintains professional affiliations and any required certifications.
• Schedule permitting, provides information about Senior CommUnity Care Program to interested individuals and groups in adherence to PACE regulations.
• Serves as community liaison between Senior CommUnity Care and community physicians, hospitals, and other health care providers in the service area

Qualifications

• Education: M.D. or DO with current state of license. DEA registration and the ability to obtain and maintain staff privileges, as needed, at Senior CommUnity Care contracted agencies. Board certified in Internal Medicine or Family Practice with advanced certification in geriatrics preferred.
• Experience: Must have a minimum of one year of experience working with a frail or elderly population. Must have experience working in a managed care environment and working with peers and other health providers to resolve utilization, quality management, performance improvement, pharmacy and therapeutics, peer review, credentialing, and physician leadership issues. Minimum three (3) years of experience in a lead administrative role.
• Must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
• Must have a valid driver's license, proof of insurance and have means of transportation.

At VOANS, we celebrate sharing, encouraging and embracing diversity. Equal employment opportunities are available to all without regard to race, color, religion, sex, pregnancy, national origin, age, physical and mental disability, marital status, parental status, sexual orientation, gender identity, gender expression, genetic information, military and veteran status, and any other characteristic protected by applicable law. We believe that blending individual strengths and unique personal differences nurtures and supports our organizations shared commitment to our mission and creates an inclusive and diverse environment where everyone feels valued and has the opportunity to do their personal best.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.