Insurance Utilization Reviewer Jobs in Washington, DC

Summary/Position Objectives:

Under the direction of the Senior Medical Director, the Medical Director will lead and participate in the Maryland Physicians Care MCO’s (MPCMCO) Medical Management Program. The Medical Director will assist in the development and implementation of comprehensive medical policies and standards of care. The Medical Director will provide leadership for the Health Management Teams. The Medical Director is responsible for the general supervision of Utilization Management, Quality Management and Inpatient Concurrent Review as well as interaction with providers.

About Maryland Care Management, Inc. (MCMI)

Maryland Care Management Inc. (MCMI) manages Maryland Physician Care's (MPC) statewide provider network of hospitals and physicians. Maryland Physicians Care has been providing services to the HealthChoice Medicaid populations since 1996, and we are proud of our footprint in the community. With over 230,000 members, MPC consistently has been one of MD's largest Medicaid-managed care organizations.

Why join us?

MCMI recognizes the importance of flexibility and offers multiple work arrangements. Along with competitive pay, we offer excellent benefits (medical, dental, and vision plans, 100% employer Term Life Insurance, Short and Long-Term Disability, 401k Employer Match up to 4%) as well as 20 days of PTO, and tuition assistance/professional development plans. Your future colleagues at MCMI are welcoming, friendly, and eager to help each other succeed. We are committed to Diversity, Equity, and Inclusion, providing organizational-wide social opportunities, and constantly improving our ongoing efforts to positively impact our members' lives

What You'll Do:

• Participate in Quality Management and Utilization Management processes.
• Confer and consult with health professionals or providers with questions related to the concurrent review process.
• Conduct peer-to-peer clinical case reviews with attending physicians, physician advisors or other ordering providers to discuss review determinations.
• Provide medical support and direction to MPC MCO’s Pre-Authorization Unit related to the authorization of providers’ requests for elective consultations, procedures, tests, and formulary.
• Identify and report quality of care issues.
• Participate in MPC/MCO Grievance and Appeals Review Processes.
• Participate in the QM/UM Committee, the Pharmacy and Therapeutics Committee, and the Credentialing Committee as needed.
• Round with concurrent review nurses on a regular basis to discuss inpatient members as determined with MD.

Secondary Functions:

• Participate in EQRO and HEDIS audits as needed.
• Accountable for other duties as assigned to include the possibility of supervising nurses and associate medical directors as required.

Knowledge and Skills:

• Knowledge and familiarity of local, regional, and national provider medical standards of care.
• Ability to establish and maintain constructive relationships with diverse members, management, employees, and vendors.
• Ability to successfully utilize Microsoft Office Suite software applications and common computer and office hardware.
• Knowledge of Medicaid and Commercial regulatory requirements is beneficial.

Education and Work Experience:

• M.D. or D.O. unincumbered license with a minimum of five (5) years of post-residency clinical experience.
• Active Board certification.
• Experience in managed care practices, processes, procedures, and operations.
• Experience in utilization review and management practices, processes, and procedures.
• Knowledge and familiarity with contracts and policies as they pertain to the managed care environment.

EEOC Statement:

Following applicable federal, state, and local laws, MCMI prohibits discrimination in employment based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, or any other characteristic protected by law. This commitment extends to all aspects of employment, including hiring, promotion, compensation, benefits, training, social and recreational programs, and all other conditions and privileges of employment.

As a healthcare organization, we recognize the vital importance of inclusivity in delivering quality care to our patients. We strive to foster an environment where individuals of all backgrounds feel respected, valued, and supported. We aim to better comprehend the unique needs of our patients and provide healthcare services that are culturally competent and sensitive.

We encourage candidates from all backgrounds to apply and join us in our mission to provide compassionate and inclusive healthcare. We believe that a diverse workforce enriches our organization and allows us to better understand, connect with, and serve our diverse patient population.