Field Medical Director, UM Physical Medicine

$31,200 - $31,200/Yr

Evolent Health - Montpelier, VT

Full-time - Senior

Montpelier, VT

Professional, Scientific, and Technical Services

About the position

The Field Medical Director for Utilization Management in Physical Medicine at Evolent Health plays a crucial role in enhancing patient outcomes through effective utilization management strategies. This position offers a non-clinical environment where the director collaborates with a diverse team of healthcare professionals to ensure quality care delivery and adherence to evidence-based practices. The role emphasizes work-life balance, continuous learning, and a culture of collaboration and innovation.

Responsibilities

• Supports pre-admission review, utilization management, and concurrent and retrospective review process.
• Participates in risk management, claim adjudication, pharmacy utilization management, and catastrophic case review.
• Assists with execution of Evolent's benchmarked Utilization/Cost Management Program and relevant Clinical Quality Improvement Programs.
• Participates in the Appeals and Grievance process to assure timely and accurate responses to members.
• Supports design and implementation of health plan medical policies and appropriate Care Management and UM goals and objectives.
• Provides clinical leadership and development for population health programs or functional areas within Medical Management.
• Assists in assuring appropriate health care delivery for the assigned membership and managing the medical costs associated with the assigned population.
• Promotes managed care systems using evidence-based medicine to educate and facilitate best practices with care management staff and medical providers.
• Participates in committees as assigned.
• Provides guidance and interpretation on issues of medical appropriateness, benefit application, and level of care necessary, including out-of-network care.
• Evaluates and ensures systems and processes to assist providers with adherence to evidence-based protocols.
• Assures compliance related to Federal, State, and local rules and regulations.

Requirements

• Active Board Certification by an American Certifying Board.
• 1+ years of Utilization Review Experience.
• Graduate of an accredited medical school (MD or DO degree required).
• Active physician license without any restrictions.
• 3-5 years of clinical practice in a primary care setting and progressively responsible medical administrative experience preferred.
• Proven ability in a medical leadership position with clinical credibility and team-building skills.
• Thorough understanding of managed care aspects, 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 is preferred.
• Not under current exclusion or sanction by any state or federal health care program.

Nice-to-haves

• Experience in a corporate matrix environment.
• Familiarity with evidence-based protocols and managed care systems.

Benefits

• Comprehensive health insurance benefits.
• Bonus component based on pre-defined performance factors.