• Assist the CMO with monitoring availability, appropriateness, and necessity of care rendered by participating providers and by out-of-plan providers • Participate in oversight and clinical decision making of the UM program, including but not limited to rendering denial determinations for services not considered medically necessary or experimental/investigation/unproven in accordance with regulatory and quality standards • Contribute to the development of quality care guidelines, internal peer review procedures, and the evaluation of medical care evaluation studies under the NHP quality assurance programs • In coordination with the CMO and Directors of Health Management and QI and Disease Management, share responsibility for the development and continued evaluation of utilization review and quality assessment processes • Provide medical consultation as requested for: • Medical/legal issues • Member grievance procedures • Development and implementation of new benefit packages and the interpretation of covered benefits in NHP contracts • Medical issues related to contract negotiations with health care providers • Determining if services to members/enrollees meet medical criteria • Promote positive relationship between NHP and medical community • Serve as liaison between NHP and providers regarding matters of medical policy and medical administration • Serve as spokesperson for NHP in the medical community and maintains appropriate contact with professional health care organizations • Participate in the ongoing recruitment of plan physicians. • Respond to physicians and other provider inquiries and complaints within established guidelines of the Executive Committee and Board of Directors • Assist in the development of appropriate medical guidelines and parameters for claims review • Assist in the training of NHP staff on matters relating to medical guidelines • Oversight responsibility for monitoring and evaluating Medicare Special Needs Plan Model of Care effectiveness • Perform second level review of provider appeals and disputes • Serve on committees as coordinated with the CMO • Assist in strategic planning targeted towards plan growth initiatives

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Impact Advisors is seeking a dynamic and motivated Training & Testing Director to join our Oracle Health team. In this role, you will be instrumental in leading enterprise-wide training and testing strategy for complex EHR implementations. This position offers a unique opportunity to contribute to client success while making a meaningful impact on the healthcare industry. - Develop and oversee role-based training programs across clinical, ancillary, and revenue cycle teams. - Lead integrated testing strategy including unit, integrated, user acceptance, and dress rehearsal testing. - Establish measurable proficiency standards and remediation strategies to ensure safe system activation. - Oversee environment management, training logistics, super user programs, and at-the-elbow support models. - Manage multidisciplinary teams and coordinate vendor resources to ensure alignment with program milestones. Qualifications - Bachelor’s degree required; advanced degree preferred. - 10+ years healthcare IT experience, 5+ years leading training and/or testing for large EHR implementations, Oracle Health (Cerner) experience strongly preferred. - Enterprise program governance. - Clinical workflow understanding. - Large-scale training operations management. - Risk identification and mitigation. - Strong executive communication skills. Requirements - Up to 50% travel. Benefits - Hourly pay rate of $90-110. - For salaried positions, this role may also be eligible for an annual performance bonus. - Additional benefits and perks may also be available, depending on the position and employment terms.

• 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

• Provide national medical oversight of all utilization management functions, ensuring alignment with organizational goals and compliance with regulatory and accreditation standards. • Serve as a clinical resource and subject matter expert to utilization management nurses, case managers, and other clinical staff. • Conduct peer reviews and clinical reviews for medical necessity determinations, complex cases, and high-cost claims. • Participate in inter-rater reliability assessments to ensure consistency and accuracy of medical review decisions. • Collaborate with Quality and Risk Adjustment teams on MRA and quality education initiatives to enhance outcomes and compliance. • Partner with leadership to develop and refine utilization management policies, protocols, and criteria based on nationally recognized standards (e.g., MCG, InterQual). • Contribute medical expertise to case management and care coordination processes, ensuring members transition to the appropriate level of care. • Support physician engagement, education, and alignment through clear communication and collaboration with internal and external providers. • Participate in ongoing evaluation and improvement of UM operations, including metrics monitoring and performance review. • Perform other duties as assigned to support clinical and operational initiatives.