PRN Medical Director BH UM
Location
France
Posted
2 days ago
Salary
$135 - $202 / hour
Seniority
Lead
No structured requirement data.
Job Description
PRN Medical Director BH UM
CareMore Health
Role Description The Medical Director Utilization Management (UM) is responsible for conducting clinical reviews of medical necessity, appropriateness, and efficiency of healthcare services, procedures, and hospital admissions. The reviewer ensures that clinical decisions align with established evidence-based guidelines, regulatory requirements, and organizational policies to promote optimal healthcare outcomes and cost-effective care. Qualifications - Medical degree (MD or DO) with board certification in a relevant specialty. - Experience in utilization management and clinical review processes. - Strong knowledge of evidence-based guidelines and regulatory requirements. Requirements - Conduct prospective, concurrent, and retrospective clinical reviews of medical services to determine medical necessity and appropriateness. - Utilize evidence-based criteria (e.g., MCG, InterQual, CMS guidelines) in evaluating requests for services. - Collaborate with nurses, case managers, and other healthcare professionals in the UM process. - Provide timely peer-to-peer consultations with requesting providers to discuss clinical decisions and alternative care options. - Participate in appeals and grievance processes by reviewing denied cases and providing justification based on medical necessity and standards of care. - Ensure all reviews are performed in compliance with federal and state regulations, accreditation standards (e.g., NCQA, URAC), and organizational policies. - Document decisions clearly and accurately in the appropriate systems. - Identify patterns of inappropriate utilization and collaborate in quality improvement initiatives. - Participate in staff training, UM committee meetings, and policy development as needed. Benefits - Competitive compensation ranging from $134.55 to $201.83. - Comprehensive health benefits. - Retirement savings plan. - Professional development opportunities.
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