Remote Utilization Management Jobs in Reston, VA

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of"people caring for people," Martin's Point employees are on amission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Employees are expected to support and demonstrate the mission, vision, and core values of Martin's Point Health Care.

Key responsibilities include:

• Partner with Health Plan senior leadership to advance clinical outcomes, affordability goals, growth targets, and overall health plan strategy.

• Provide clinical leadership across utilization management, care management, population health, quality, pharmacy, medical policy, payment policy, and clinical program development.

• Lead cross-functional collaboration among Medical Directors, Medical Economics, Quality, Network, Compliance, Pharmacy, Operations, and Clinical Programs.

• Support compliance with government program requirements, including clinical appeals and grievances, using sound clinical evidence and medical judgment.

• Use clinical, quality, utilization, and financial data to identify trends, assess performance, and recommend actionable interventions.

• Develop strategies to improve medical expense management, appropriate utilization, quality of care, and population health outcomes.

• Provide clinical input into product design, Medicare bids, risk adjustment, STARS, HEDIS, value-based arrangements, and clinical integration initiatives.

• Communicate complex clinical, regulatory, and operational information clearly to executive, provider, clinical, and non-clinical audiences.

• Support appropriate utilization of services through strong partnership with Utilization Management, Care Management, and physician leaders.

• Represent the organization with regulatory entities, professional societies, providers, network partners, and external stakeholders, as appropriate.

• Build and strengthen relationships with hospitals, physicians, and other health care providers to support network engagement and performance goals.

• Support strategies tied to population health, care management, provider performance, and contractual outcomes.

• Lead, support, and develop physician leaders and clinical team members, as assigned.

• Medical Degree, MD or DO, from an accredited medical school.

• Board certification in a relevant medical discipline or specialty.

• Active, unrestricted medical license, or ability to obtain licensure in a state relevant to the role.

• Ten or more years of professional experience, including clinical practice experience.

• Health plan, managed care, or payer experience in a Medical Director or comparable physician leadership role.

• Demonstrated experience working across health plan functions, such as utilization management, care management, quality, appeals and grievances, population health, medical economics, provider relations, pharmacy, compliance, or network.

• Experience using clinical, quality, utilization, or financial data to guide decisions, develop interventions, and measure outcomes.

• Strong cross-functional leadership skills, with the ability to align clinical, operational, financial, and regulatory priorities.

• Strong verbal, written, and presentation skills, including the ability to communicate effectively with executive, clinical, provider, operational, and regulatory audiences.

• Ability to influence, collaborate, and build credibility with internal and external stakeholders.

• Strong analytical, problem-solving, and decision-making skills.

• Demonstrated alignment with Martin's Point Health Care values.

• Experience with Medicare Advantage, TRICARE, or other government-sponsored programs.

• Experience with STARS, RAF, risk adjustment, Medicare bids, HEDIS, or value-based care arrangements.

• Prior management or physician leadership experience.

• Experience supporting medical policy, payment policy, pharmacy, or clinical program development.

• Experience building relationships with network physicians, hospitals, and community providers.

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org

Do you have a question about careers at Martin's Point Health Care? Contact us at:jobinquiries@martinspoint.org