Medical Director - Utilization Management/Care Management, Select Health

Responsibilities

• Strategic Leadership: Develop and implement UM and CM strategies using data analytics, technology, and cost-benefit analysis to optimize covered services and care management efforts.
• Policy & Process Development: Participate in the creation, revision and enforcement of UM/CM policies, procedures, and protocols to meet regulatory and other accreditation requirements .
• Operational Oversight: From a clinical perspective, manage provider reviewers, concurrent reviews, prior authorizations, medical claims reviews, appeals, and grievances and ensure timely and accurate service authorizations consistent with regulatory and accreditation standards .
• Efficiency & Innovation: Identify process improvements, redesign workflows, and implement processes including auto-approvals , alternative site criteria evaluation , artificial intelligence solutions and prior auth orization efficiency where appropriate to reduce administrative burden.
• Pro- Active Care (Value-based Care): Participate in system innovation opportunities such as risk-based contracting, appropriate reduction of prior authorization or other identified opportunities to affect administrative simplification and reduce abrasion for members and providers.
• Data & Trend Analysis: Monitor utilization trends, measure productivity metrics, and report on cost savings and quality outcomes across areas of responsibility .
• Provider & Vendor Management: Build and maintain strong relationships with such Select Health required vendors and clinical teams necessary to improve care quality and efficiency.
• Compliance & Quality: Ensure adherence to state/federal regulations, accreditation standards, and contractual obligations; conduct provider education and training as necessary to facilitate compliance and adherence to quality measures .
• Team Leadership: Supervise and mentor UM/CM staff, provide executive-level guidance, and support workforce planning as needed .
• Special Projects: Lead initiatives to improve member/provider experience, reduce unnecessary services, and enhance clinical decision support.

Requirements

• Leadership
• Communication
• Taking Initiative
• Performance management
• Process Improvements
• Teamwork
• Workflow optimization
• Process documentation
• Health plan operation
• Federal, state and local regulations
• Computer Literacy
• Additional Details
• FTE: 1.0
• Salary: $332,300 - 377,400 based on relevant experience
• Eligible for an annual leadership incentive opportunity based on system goals
• In addition to the annual salary, to show our commitment to you and assist with your transition, we may offer a sign-on and relocation bonus when applicable.
• Medical Doctor or Doctor of Osteopathic Medicine degree with Board Certification in one of the following areas: Internal Medicine, Pediatrics, Family Practice, Psychiatry or Emergency Medicine.
• Requires current MD or DO licensure within the State of Utah, Idaho, Nevada or Colorado
• Five years of experience in clinical practice.
• Utilization management, care management and/or experience in policy related work for a health plan or managed care organization.
• Previous management experience.
• Experience with financial and medical expense management.
• Understanding of health care delivery system as it relates to government programs and agencies.
• Excellent communication skills including ability to establish and maintain rapport with coworkers, providers, brokers, employers, plan members, representatives/executives from other health care entities, government and regulatory bodies and others in the community.
• Physical Requirements
• Ongoing need for employees to see and read information, documents, monitors, identify equipment and supplies, and be able to assess member, provider, and coworkers' needs.
• Frequent interactions with colleagues and providers require employees to verbally communicate as well as hear and understand spoken information, needs, and issues quickly and accurately.
• Frequent computer use for typing, accessing needed information, etc.
• Location:
• SelectHealth - Murray
• Work City:
• Murray
• Work Sta

Benefits

Additional Information

Job Description: Select Health, a regional health plan with over a million members serving all lines of business in Utah, Idaho, Nevada and Colorado, is seeking an experienced Medical Director with expertise in Utilization Management (UM), Care Management (CM) and Health Plan accreditation and other operational and regulatory functions. The Medical Director of Utilization Management/Care Management, reporting directly to the Chief Medical Officer, leads the UM and CM functions for Select Health from a clinical perspective, ensuring that care services are high quality, appropriate, efficient and in compliance with regulatory and accreditation standards. The role combines oversight of the UM and CM functions with Select Health strategies to ensure members receive coverage and services for high-quality, appropriate, efficient, and cost-effective care. Essential Functions

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