UM Medical Director - WellMed - San Antonio, TX(Job Number:708435)
Clinical Services is focused on driving measurable and meaningful improvement in the use of evidence-based medicine, patient safety, practice variation and affordability. In serving our Medicare, Medicaid, and commercial members & plan sponsors, our Clinical Services teams partner with our network of physicians, hospitals and other health care professionals to achieve these goals. We are committed to our mission of helping people live healthier lives.
The UM Medical Director is responsible for the development, implementation and effectiveness of UM program; ensures provision of quality health care services in most efficient and cost effective manner. Supervises the medical management of the UM program and offers guidance to providers in the delivery of healthcare. They will serve as a voting member of the UM committee to ensure consistency in review of criteria, medical necessity and equitable administration of benefits. Also, they’ll act as a resource to the credentialing committee in efforts to provide patients with a demographically efficient network with a collection of multi-specialties who will provide quality medical care.
This individual will have accountability for UM medical management and work to solve problems by gathering and reviewing clinical data, and selecting the best solution from identified alternatives. Decision-making is usually based on prior practice or policy, with some interpretation of criteria and medical necessity. They will apply individual reasoning to the solution of a problem, devising or modifying processes and writing procedures. Occasionally they will need to be insolvent for determinations that may not be favorable, but require direction from a management affiliate. This Medical Director will also participate in monthly meetings in San Antonio.
- Develops and maintains 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 UM activities
- Develops strategies for improving performance in medical management
- Participates in case review and medical necessity determination
- Oversees the development of UM policies and procedures
- Analyzes aggregate data and reports to primary care physician
- Liaises between physicians and health plan Medical Directors
- Reviews specialty provider credentialing applications according to federal and state regulatory standards
- 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
- Seeks ways to improve job efficiency and makes suggestions to improve operations that meet national standards as well as company needs
- Takes ownership of the UM plan and provides constructive information to minimize problems and increase customer satisfaction
Job Clinical Analysis & Consulting
Primary Location US-TX-San Antonio
Organization WellMed Medical Mgmt, Inc
Number of Openings 1