Utilization Management Jobs in Dover, DE (NOW HIRING)

The Medical Director, Neonatology is responsible for providing subject matter expertise and medical leadership in the development of utilization management, care management and quality of care programs for infant and neonatology services.

• Work directly with Vice Presidents of Utilization Management, Care Management and Medical Directors to achieve desired utilization, care management and quality of care objectives for this newborn and infant members and their mothers
• Support staff by providing training, clinical consultation, and clinical case review for members
• Provide prior authorization medical reviews, consultation and clinical review services
• Participate in peer-to-peer discussions
• Provide provider education, training, data sharing, performance evaluations and orientation to the plan
• Provide physician review for clinical appeals cases
• Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
• Participates in quality improvement initiatives, case management activities and member safety activities (i.e. incident management
• Oversight and quality improvement activities associated with case management activities
• Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to managed care plan staff and providers as appropriate
• Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards
• Participate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives
• Collaborate with market/product leaders to help define market strategy
• Work with market leaders to be a liaison to community based organization and health systems regarding neonatal care both prevention and care coordination and management
• Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
• Actively participate in Utilization Management (UM) rounds and education of UM staff on NICU utilization management, levels of care and quality of care
• Participate in the development /ongoing improvement in the transitions of care for NICU members that graduate from NICU
• Actively participate in creating of formal clinical policy for NICU and post NICU transitions/care management
• Perform any other job duties as requested

• Completion of an accredited Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic (DO) medicine is required
• Successful completion of a residency training program in pediatrics and neonatology fellowship required or equivalent experience
• Minimum of five (5) years of clinical practice experience is required
• Managed care medical review/medical director experience is preferred
• Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is desirable

• Basic Microsoft Word skills
• Excellent communication skills, both written and oral
• Ability to work well independently and within a team environment
• Ability to create strong relationships with Providers and Members
• High ethical standards
• Attention to detailCritical listening and systematic thinking skills
• Ability to maintain confidentiality and act in the company’s best interest
• Ability to act with diplomacy and sensitivity to cultural diversity
• Decision making/problem solving skills
• Conflict resolution skills
• Strong sense of mission and commitment of time, effort and resources to the betterment of the communities served

• Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements is required
• Board Certification, preferably in primary care specialty (Pediatrics) is required as well as board certification in Neonatology
• Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer)

• General office environment; may be required to sit or stand for extended periods of time
• May be required to work evenings/weekends
• May be required to travel to fulfill duties of position

$195,200.00 - $341,600.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Organization Level Competencies- Fostering a Collaborative Workplace Culture- Cultivate Partnerships- Develop Self and Others- Drive Execution- Influence Others- Pursue Personal Excellence- Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time.

CareSource is an Equal Opportunity Employer.

We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.