Utilization Management Jobs in Rochester, NY (NOW HIRING)

Job Description:

The Medical Director participates in the broad array of activities of the Medical Services area including, but not limited to, Medical and Pharmacy Utilization Management, quality management, member care management, and medical policy processes, and support for our various lines of business. The incumbent also provides input into the development of policies, programs and strategic objectives that cover Medical Management Services through their required participation in various committees and when assigned to other committees or workgroups as requested by leadership. They also act as a liaison with local physicians and hospitals and keep abreast of practice patterns, issues, and concerns of their regional medical community, as well as support our Provider Relations team as requested.

This position is occasionally required to work evenings during high volume periods and staff shortages, e.g. cross-coverage vacations.

Essential Accountabilities:

Level I

• Reviews and makes recommendations and/or decisions on Utilization or Case Management activities. Utilization review activities include: reviews of requests for broad range of medical services including medications, medical and surgical services at first level, appeal and inquiries.
• Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations with providers and external physicians.
• Conduct clinical appeal case reviews and may require peer-to-peer discussions with providers regarding UM case review determinations.
• Provides clinical expertise on ARD cases, Quality of Care cases, clinical editing, coding reviews and inquiries.
• Makes accurate and consistent interpretation of integral medical policy, contract benefits and State and Federal Mandates and maintains current and working knowledge of Utilization Management Standards.
• Clinical skills are excellent and evidence-based medicine skills are such that the individual provides review oversight for a broad array of clinical services.
• Reviews and makes recommendations on medical policies, guidelines and medical criteria.
• Assists with training medical director colleagues and nursing staff, including leadership of teaching grand round activities, and case consistency conferences.
• Regular attendance at assigned meetings including, but not limited to, weekly Medical Director staff meetings, weekly case consistency meetings, monthly medical policy meetings, as well as, departmental and divisional meetings, including in person meetings.
• Serves as a resource and consultant to other areas of the company.
• May be required to represent the company to external entities and/or serve on internal and/or external committees.
• May chair company committees.
• May develop and propose new medical policies, in conjunction with Medical Services team and Medical Policy Department, based on changes in healthcare.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are compliant with these requirements.
• Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

• Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality cost and outcomes.
• Identifies and develops opportunities for innovation to increase effectiveness and quality.
• Serves as a mentor or coach to other Medical Directors and other colleagues in quality and performance improvement processes. Functions as a mentor and resource throughout the workday in training medical director colleagues, as needed.
• Conduct clinical appeal case reviews and may require peer-to-peer discussions with providers regarding UM case review determinations.
• Provides input into the utilization management program policies and procedures.
• Serves as a resource and consultant to other areas of the company.
• Assists in many aspects of frontline UM during high peak activity or staff outages.

Minimum Qualifications:

NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels

• Minimum of seven (7) years of clinical practice experience after completion of all graduate medical education training, including residency and fellowship (when applicable).
• Medical Degree: MD or DO from an accredited institution required.
• Active board certification in Professional Medical Specialty.
• Active unrestricted medical license to practice medicine in a state or territory of the United States Doctor of Medicine or Doctor of Osteopathic Medicine.
• The Physician is not the subject of any pending professional disciplinary action that could result in the impairment of their ability to practice medicine.
• Knowledge of applicable state and federal laws, NCQA standards, and Utilization Management.
• Demonstration of effective use of word processing, spreadsheet, email.
• Must be able to research clinical issues.
• Strong interpersonal skills essential for communication to staff at all levels of the organization.
• Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem-solving skills.
• Ability to work within changing business environment and balance patient advocacy with business needs.
• Successful ability to assess complex issues, to determine and implement solutions, and resolve problems.
• Demonstrated sensitivity to culturally diverse situations, participants, and customers/members.

Level II (in addition to Level I Qualifications)

• Minimum 2-3 years of experience in medical management, utilization review and case management.
• Knowledge of managed care products and strategies.
• Demonstrated ability to educate colleagues and staff members.
• Experience with managing multiple projects in a fast-paced matrixed environment.
• Demonstrated ability to educate colleagues and staff members.
• Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem-solving skills.
• Knowledge of credentialing, quality, NCQA/HEDIS/CMS and/or Medicaid Star Ratings, and/or value-based payment programs is a plus.
• Strong verbal presentation skills to lead internal and external discussions including presenting at board level when requested.
• Previous experience managing physicians, nurses or employees preferred.
• Service marketing, sales and business acumen experience preferred.

Physical Requirements:

• Ability to work prolonged periods sitting at a workstation and working on a computer.
• Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
• Typical office environment including fluorescent lighting.
• Ability to work in a home office for continuous periods of time for business continuity.
• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
• Ability to lift, carry, push or pull 15 pounds or less.
• Manual dexterity including fine finger motion required.
• Repetitive motion required.
• The ability to hear, understand and speak clearly while using a phone, with or without a headset.

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In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

$202,000.00 - $303,000.00

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.