Utilization Management Director jobs in Texas

Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together.  

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.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. 

Primary Responsibilities:

• 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.) or Doctor of Osteopathy (D.O.) degree
• Board Certified Family Practitioner or Internal Medical Specialist
• Unrestricted licensed in Texas, Florida, Georgia, or New Jersey
• 5 years of clinical practice experience
• 2 years of experience in utilization management activities
• Proficiency with Microsoft Office applications

Preferred Qualifications:

• Unrestricted license in New Mexico
• 2 years of experience with acute admission experience
• 2 years of experience working in a managed care health plan environment
• Bilingual (English/Spanish) fluency

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington residents is $286,104 to $397,743 annually. Salary Range is defined as total cash compensation at target. The actual range and pay mix of base and bonus is variable based upon experience and metric achievement. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission. 

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.