Medical Director Utilization Management- Johns Hopkins Health Plans

Johns Hopkins - Hanover, MD

Full-time - Senior

Hanover, MD

Educational Services

About the position

The Medical Director at Johns Hopkins Health Plans is responsible for overseeing utilization management activities across four lines of business. This role involves making medical necessity decisions, developing clinical policies, and leading performance improvement initiatives. The Medical Director collaborates with cross-functional teams to enhance clinical quality and operational efficiency while serving as a clinical expert within the organization.

Responsibilities

• Review requests and appeals for inpatient care, skilled nursing facility stays, acute rehabilitation, outpatient services and procedures, pharmaceuticals, and durable medical equipment (DME).
• Apply appropriate policies, guidelines, or regulatory directives to make sound medical necessity decisions.
• Participate in, develop, and lead clinical initiatives aimed at improving members' health outcomes.
• Serve as a clinical expert on committees.
• Collaborate with other departments on projects to enhance clinical quality, operational efficiency, and financial performance.
• Act as a preceptor for medical residents and administrative fellows, providing clinical and health plan guidance.

Requirements

• Medical Degree from an accredited Medical School.
• Unrestricted license as M.D., licensed in Maryland.
• Minimum of 5 years of health plan experience.
• Minimum of 5 years of clinical practice experience.
• Experience with government payers (Medicaid, Medicare) preferred.
• Ability to utilize multiple software programs and understand patient data reports, utilization reports, and measure and assess outcomes.

Nice-to-haves

• Experience with Emergency Department Sudden and Serious/Prudent Layperson review is strongly preferred.
• Experience with health plan Payment Integrity functions is strongly preferred.

Benefits

• Diversity and Inclusion initiatives
• Commitment to employee health and well-being