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Medical Director, Utilization Management

Company: Evolent Health
Location: Sacramento
Posted on: September 24, 2022

Job Description:

Your Future Evolves HereEvolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Evolenteers make a difference wherever they are, whether it is at a medical center, in the office, or while working from home across 48 states. We empower you to work from where you work best, which makes juggling careers, families, and social lives so much easier. Through our recognition programs, we also highlight employees who live our values, give back to our communities each year, and are champions for bringing their whole selves to work each day. If youre looking for a place where your work can be personally and professionally rewarding, dont just join a company with a mission. Join a mission with a company behind it.Why Were Worth the Application:

  • We continue to grow year over year.
  • Recognized as a leader in driving important diversity, equity, and inclusion (DE&I) efforts (https://www.evolenthealth.com/diversity) .
  • Achieved a 100% score two years in a row on the Human Rights Campaign's Corporate Equality Index making us a best place to work for LGBTQ+ equality.
  • Named to Parity.orgs 2020 list of the best companies for women to advance (https://www.evolenthealth.com/about-us/press-releases/8579/evolent-health-named-to-parity.org%E2%80%99s-best-companies-for-women-to-advance-list-2021) .
  • Continued to prioritize the employee experience and achieved an 87% overall engagement score on our last employee survey.
  • Published an annual DE&I report (https://dev.evolenthealth.com/sites/default/files-public/Evolent%20Health%202020%20DE%26I%20Annual%20Report.pdf) to share our progress on how were building an equitable workplace.What Youll Be Doing:What Youll Be Doing: Supports design and implementation of health plan medical policies, and appropriate UM goals and objectives. Interfaces with provider community in regards to Utilization Management and evidence based medicine Provides professional leadership and direction to the functions within the Utilization Management Department Responsible and accountable for executing the Utilization/Cost Management Program and relevant Clinical Quality Improvement Programs in partnership with the Managing Director, Utilization Management and Market Medical Directors. Assists the Market Medical Directors with activities to promote positive community relations. Assures plan conformance with legal and regulatory requirements. Assists the Market Medical Directors in creating and maintaining a system that gives feedback to providers individually and collectively regarding managed care effectiveness of individual providers and networks. Assists the Market Medical Directors and in designing and implementing corrective action plans to address issues and improve plan and network managed care performance. Partners with Market Medical Directors in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes. Achieves and maintains Evolent Healths benchmarked utilization and cost management (UM) goals and clinical quality improvement (QI) objectives. Provides periodic written and verbal reports and updates regarding Utilization Management as required in the Quality Management Program description, the Annual Work Plan and Community Care policy and procedures to various plan committees, the health plan Market Medical Director. Supports URAC, AHCA and NCQA qualification activities. Assists in preparation for site visits and responds to accrediting and regulatory agency feedback. Supports pre-admission review, utilization management, and concurrent and retrospective review process. Participates in risk management, claim adjudication, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orientation, etc. Conducts and/or supports quality improvement and outcomes studies related to Utilization Management as directed by the state Departments of Health, the Quality Management Committee, Medical Advisory Committee, Peer Review Committee and management. Reports findings. Monitors member and provider satisfaction survey results with the UM process and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants. Assists, as appropriate, with the contracting process of providers, hospitals, ancillary providers, and emergency and other support services, and evaluates the medical aspects of provider contracts. May chair or assist in chairing (or delegates management of) Advisory Committees of the health plan which include (but are not limited to) the Peer Review Subcommittee and the Credentialing Subcommittee of the Quality Management Committee. Participates in key marketing activities and presentations. Promotes wellness and ensures programs of prevention, education and outreach to members and providers consistent with companys mission, vision and values. Maintains up-to-date knowledge of new information and technologies in medicine and their application to the health plan. Contributes to and oversees in-service training and education of professional staff. Represents at medical group meetings, conferences, etc. as appropriate and requested by Managing Director and/or Market Medical Directors Participates in the development of strategic planning for existing and expanding business. Recommends changes in program content in concurrence with changing markets and technologies. Participates in key marketing activities and presentations, as necessary, to assist the marketing and branding efforts. Ensures that the Utilization Management Program is available on a 24 hour basis to respond to authorization requests for emergency and urgent services and is available, at a minimum, during normal working hours for inquiries and authorization requests for non-urgent health care services.Population health collaborative care management leadership Assists in assuring appropriate health care delivery for the assigned membership and managing the medical costs associated with the assigned population. Helps recruit, develop and motivate population health-care management staff, as requested or appropriate. Promotion of managed care systems using evidence-based medicine to educate and facilitate best practices with care management staff and medical providers Understand and supports stratification, continuous evaluation and re-stratification of population for appropriate resource allocation.Physician and provider relationship management Responsible directing compliance with physicians and other providers to improve the quality and efficiency of care in the network and integrate these providers into our clinical initiatives. Coordinates utilization review activities (by either by Evolent staff or contracted utilization management care managers) at client facilities on a regular basis, identifies key issues facing leaders and works collaboratively with leadership to accomplish mutually agreed upon goals. Creates and maintains a system that gives feedback to providers individually and collectively regarding managed care effectiveness of individual providers and networks and coordinates corrective actions with Market Medical Directors. Establishes a culture where delivering the highest quality yields lowest cost. Provides critical thinking for analysis, evaluation and modification of data reports (e.g., medical, pharmacy, quality) and assist Evolent stakeholders with the translation of information to knowledge and action to contracted physicians and providers. Develop, maintain and grow relationships with key clinical leaders with the assigned market.Quality of care and service delivery Provides guidance and interpretation on issues of medical appropriateness, benefit application as appropriate, level of care necessary to include out-of-network care. Maintains up-to-date knowledge of new information and technologies in medicine and their application to Evolent s clients Evaluates and ensures systems and processes to assist providers with adherence to evidence based protocols Participates in the Appeals and Grievance process, as necessary, to assure timely, accurate responses to members Assures compliance related to Federal (e.g., CMS), State (e.g., Insurance commission) and local rules and regulations.Preferred Experience We Look For: Graduate of an accredited medical school. M. D. Degree is required. MBA, or a Master's Degree is preferred in healthcare, or other related fields of study. 5 years of clinical practice in a primary care setting and progressively responsible medical administrative experience preferred. Proven ability in medical leadership position possessing clinical credibility with peers and the ability to be a team player and team builder. A thorough comprehension of all aspects of managed care, including HMOs, PHOs, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, pharmacy management, and patient centered medical home concepts. Excellent interpersonal, verbal, and written communication skills. Consistently completes continuing education activities relevant to practice area and needed to maintain licensure. Ability to navigate in a corporate matrix environment.Technical Requirements:Currently, Evolent employees work remotely temporarily due to COVID-19. As such, we require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.Evolent Health is committed to the safety and wellbeing of all its employees, partners and patients and complies with all applicable local, state, and federal law regarding COVID health and vaccination requirements. Evolent expects all employees to also comply. We currently require all employees who may voluntarily return to our Evolent offices to be vaccinated and invite all employees regardless of vaccination status to remain working from home. Certain jobs require face-to-face interaction with our providers and patients in client facilities or homes. Employees working in such roles will be required to meet our vaccine requirements without exception or exemption.Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.Compensation Range: The minimum salary for this position is $, plus benefits. Salaries are determined by the skill set required for the position and commensurate with experience and may vary above and below the stated amounts.

Keywords: Evolent Health, Sacramento , Medical Director, Utilization Management, Executive , Sacramento, California

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