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Job Details

Job Description

• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Perform utilization review for requests for services including but not limited to inpatient, outpatient, pharmacy and dental. This will include peer-to-peer discussions with providers.

• Serve on and support the functions of committees including but not limited to the Utilization Management Committee and Pharmacy & Therapeutics Committee.

• Advise the HealthCare Senior Management team regarding the utilization of health care services and interventions to promote the effective delivery of medically necessary services.

• Participate and/or lead rounds including but not limited to disease management, care management or admissions.

• Provide support for Plan accreditation processes (NCQA), Utilization, Quality and Disease Management programs.

• Support ongoing activities in OB, pediatric, adolescent, adult preventative, and geriatric care.

• Develop and or revise practice guidelines for acute and chronic care.

• Develop and implement policies and procedures required to promote effective utilization management and achieve established targets.

• Collaborate with HealthCare Economics and Finance to continuously improve the collection and use of data describing resource utilization and outcomes.

• Represent HealthCare Management internally and externally at the direction of the VP Chief Medical Officer.

• Develop and implement work plans to optimize appropriate utilization and quality targets as directed by the VP Chief Medical Officer.

• Perform other job duties as assigned.

• Required Education and Experience:

• Medical Physician (MD or DO) required.

• Pennsylvania Medical License without restriction.

• Board Certification in a specialty (primary care preferred)

• Graduate business degree is a plus (MBA, MMM, etc.).

• Minimum 5 years post-residency experience in the clinical practice of medicine.

• Managed care experience, with responsibility for utilization management.

• Skills/Abilities:

• Excellent organizational, interpersonal, time management and communications skills.

• Strong leadership skills.

• Strong conflict resolution and independent decision-making skills.

• Expert project management ability.

• Strong influencing, negotiation and analytical skills.

• Working knowledge of PC based applications such as Excel, Access and Word.

• Knowledge of the principles of Utilization, Quality and Care Management.

Work Shift

Worker Sub Type

Employee Entity

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time(including per diemcolleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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