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    Medical Director Care Management - Jacksonville, United States - GuideWell

    GuideWell
    GuideWell Jacksonville, United States

    2 weeks ago

    Default job background
    Description

    • Perform all types of utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals
    • Discuss cases with physician providers (Peer to Peer)
    • Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests
    • Collaborate with Case Managers to provide support and guidance on cases needing physician assistance
    • Meet any established metrics (compliance and accreditation) related to UM review efficiency, timeliness, and quality of review
    • Participate in ongoing Inter-rater reliability (IRR) audits and any other health plan audits as necessary
    • As necessary, assist nurses and other staff in understanding the principles behind appropriate utilization review and interpretation and application of benefits and policies
    • Participate in the development and review of Medical and Pharmacy policies as assigned
    • Support the organization as a subject matter expert
    • Perform as lead Medical Director consultant for one sub-category of utilization management, such as commercial or Medicare medical policy
    • Perform other duties as assigned and needed by the organization

    Job Requirements:


    • Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine
    • Board Certification or Board eligibility by American Board of Medical Specialties or equivalent
    • 5+ years' clinical experience
    • Experience working in a fast-paced environment
    • Experience working both independently and in a team environment
    • Exceptional verbal and written communication

    Preferred:


    • Physician reviewer or utilization management experience
    • Health payor experience
    • Primary Care Specialty physician experienc

    What We Offer:


    As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

    To support your wellbeing, comprehensive benefits are offered.

    As an employee, you will have access to:
    Medical, dental, vision, life and global travel health insurance;

    Income protection benefits:
    life insurance, Short- and long-term disability programs;
    Leave programs to support personal circumstances;
    Retirement Savings Plan includes employer contribution and employer match;
    Paid time off, volunteer time off, 10 holidays and two flexible Well-Being days
    Additional voluntary benefits available; and
    A comprehensive wellness program

    Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

    To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

    Annualized Salary Range:
    $216,000 - $351,000

    Typical Annualized Hiring Range:
    $216,000 - $270,000


    Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.


    We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.

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