Utilization Management Medical Director - WellMed - San Antonio, TX

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Compassion. It's the starting point for health care providers like you and it's what drives us every day as we put our exceptional skills together with a real feeling of caring for others. This is a place where your impact goes beyond providing care one patient at a time. Because here, every day, you're also providing leadership and contributing in ways that can affect millions for years to come. Ready for a new path? Learn more, and start doing your life's best work. SM

Our teams are helping people from around the world. We can bring out your best as you put your listening, analytical and problem solving skills to work in a setting that is geared to helping improve lives and enhance health care for millions. Here, you'll discover a wealth of pathways for professional growth within Customer Service, Billing, Claims, Enrollment & Eligibility and across our global economy. Join us and find out why this is the place to do your life's best work. SM

Looking for a chance to drive measurable and meaningful improvement in the use of evidence-based medicine, patient safety, practice variation and affordability? You can make a difference in serving our Medicare, Medicaid and commercial members and plan sponsors. Be part of changing the way health care is delivered.

We are looking for a Utilization Management Medical Director to join our WellMed medical team in the San Antonio office. This requisition is part of the comprehensive investment necessary for the Texas DSNP Risk Transfer population. The investments are focused on the delivery of commitments, as well as completely and accurately capturing the patient diagnosis and assist OptumCare member servicing goals. This position is needed to support department work for full risk/full delegation.

The Market Medical Director for Utilization Management will support WellMed Medical Management, Inc. by making utilization management determinations, identifying utilization trends suggesting possible over or under utilization of services and proactively suggesting improvements to WellMed Medical Management's utilization management program. The position will also provide appropriate mentoring and leadership to physicians in the market as well as develop relationships to support growth and fiscal responsibility.

Primary Responsibilites:
  • Assists in development and maintaining an efficient UM program to meet the needs of the health plan members and commensurate with company values
  • Educates primary care physicians regarding systems, structures, processes and outcomes necessary for assurance of regulatory compliance related to market activities
  • Develops strategies for improving all aspects of market performance including RAPS, membership, and medical management
  • Participates in case review and medical necessity determination
  • Conducts post service reviews issued for medical necessity and benefits determination coding
  • Analyzes aggregate data and reports to primary care physician
  • Serves as the liaison between physicians and health plan Medical Directors
  • Supervises the functions of Care Coordination
  • Assesses the effectiveness of the specialty network to ensure members have access to multi-specialties within their demographic area
  • Represents the providers as an influence to the credentialing committee
  • Reviews policies and procedures of credentialing department and offers guidance for revision and implementation of process
  • Educates primary care network and assists in problem resolution
  • Assists in development of medical management protocols
  • Performs analysis of utilization data and suggests/implements corrective action plans with network physicians
  • Performs all other related duties as assigned

Customer Service
  • Oversees and insures physician compliance with UM plan
  • Evaluates performance of physicians in regards to established goals and objectives of the company
  • Performs all duties with physicians and medical group staff in a professional and responsible manner
  • Responds to physicians in a prompt, pleasant and professional manner
  • Respects physician, patient, and organizational confidentiality
  • Educates medical groups regarding UM policies, procedures and government-mandated regulations
  • Provides quality assurance and education of current medical technologies, review criteria, accepted practice of medicine guidelines, and UM policies and procedures with counsel when criterion are not met

Personal and Physician Development
  • Strives to personally expand working knowledge of all aspects of the UM department
  • An active participant in physician meetings
  • Orients new physicians to ensure understanding of company policy and resources available for physician support
  • Encourages teamwork and cooperation with medical group staffs in order to prepare for cross training and float positions
  • Assists in the growth and development of subordinates by sharing special knowledge with others and promotes continued education classes
  • Attends continuing education classes to keep abreast of medical advancements and innovative practice guidelines

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:
  • Doctor of Medicine (M.D.) degree
  • Board Certified/Board Eligible Family Practitioner or Internal Medical Specialist
  • Five or more years of clinical practice experience
  • Two or more years of experience in utilization management activities
  • Proficiency with Microsoft Office applications
  • Full COVID-19 vaccination is an essential requirement of this role. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance
Preferred Qualifications:
  • Two years of experience working in a managed care health plan environment
  • Bilingual (English/Spanish) fluency

Transforming health care and millions of lives starts with the values you embrace and the passion you bring. Find out more and join us. It's an opportunity to do your life's best work.(sm)

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 380,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job Keywords: Utilization Mangagement, Medical Director, Texas, TX