Medical Director, Utilization Management - Memorial Hermann Health Plan

Houston, Texas
Jan 09, 2018
Jan 17, 2018
Contract Type
Full Time
Supp Medical Director, Utilization ManagementHealth Solutions

Job Description
Responsible for providing direct clinical oversight of Medical Management functions for Memorial Hermann Health Plan (MHHP) including Utilization Review, Clinical Appeals and Grievances, Medical Policy Development and Medical Cost Management for all product lines. In addition the Medical Director, Utilization Management works collaboratively with other plan functions that interface with medical management such as provider relations, member services, benefits and claims management, etc. and assists the Chief Medical Officer (CMO) in short-term and long-term program planning, total quality management/quality improvement and external relationships. The primary goal of the Medical Director, Utilization Management is to assure the plans members are provided high quality, cost effective healthcare, while supporting organization objectives, and meeting contractual and regulatory requirements.

Typically reports to the Chief Medical Officer, Memorial Hermann Health Plan.


  • Medical Doctorate (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school required.
  • Satisfactory completion of an American Council of Graduate Medical Education (ACGME) accredited residency program required.
  • Master’s Degree in Public Health may be substituted in lieu of two (2) years of required clinical experience.

  • Unrestricted MD or DO license in the State of Texas required.
  • Board Certification or Board Eligible for a primary care or medical specialty required.
  • Certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management preferred.

  • Five (5) years of clinical experience in the practice of medicine in fields related to a managed care setting required.
  • Two (2) years of managed care experience on the payor or provider side related to utilization management, case management and/or discharge planning required. Health Plan utilization review experience preferred. Experience in the principles and practices of quality improvement, including HEDIS and/or STARS preferred.
  • Ability to meet the MHHP’s credentialing and re-credentialing requirements.
  • Basic knowledge of managed healthcare as applied to government sponsored programs including Medicare Advantage.
  • Very strong facilitation, problem solving and conflict resolution skills.
  • Strong collaboration skills with demonstrated ability to create and foster a collaborative work environment and maintain effective, high performance teams.
  • Very strong interpersonal skills, with the ability to establish and maintain effective working relationships with individuals inside and outside MHHP.
  • Ability to handle confidential information with appropriate discretion.
  • Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring One Memorial Hermann.

Principle Accountabilities:
  • Provides clinical leadership for medical management functions including utilization review, as well as, resolving medical claims review, grievances, appeals and other medical management issues.
  • Works closely with the CMO to identify medical service issues that have an impact on plan benefits and their administration, develop action plans and monitor results.
  • Identifies and analyzes, and assists in identifying and analyzing care and quality issues and trends; makes recommendations based on findings; develops and implements agreed upon changes.
  • Provides clinical expertise needed to effectively and efficiently resolve complex, controversial and/or unique administrative circumstances.
  • Conducts clinical reviews and makes UM/CM/QM decisions for prior, concurrent and retro authorizations, and appeals; approves/denies or offers medical alternatives according to MHHP medical review criteria, Interqual review criteria and/or Medicare NCD and LCD decisions as needed to appropriately adjudicate reviews.
  • Establishes and maintains working relationships with providers, provider organizations, case management and other stakeholders in support of high quality, cost effective care for members.
  • Collaborates with leadership to ensure medical compliance with internal, regulatory and accreditation requirements.
  • Designs and implements clinical policies, procedures and programs.
  • Serves on Utilization Management/Quality Improvement, Peer Review and Physician Advisory Committees; serves on other committees as required.
  • Assists with development and implementation of Quality Improvement activities with respect to STARS and HEDIS.
  • Assists with development of corporate and department budgets, goals and metrics.
  • Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
  • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
  • Other duties as assigned.

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