Evolent

Field Medical Director, UM Physical Medicine

Evolent

full-time

Posted on:

Location Type: Remote

Location: United States

Visit company website

Explore more

✨ AI Apply
Apply

Job Level

Lead

About the role

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

Requirements

  • Active Board Certification by an American Certifying Board (If a specialty or subspecialty, must have that BC)
  • 1+ years of Utilization Review Experience
  • Graduate of an accredited medical school. Either MD or DO degree is 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 medical leadership position possessing clinical credibility with peers and the ability to be a team player and team builder.
  • A thorough understanding of all aspects of managed care, 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, including Medicare or Medicaid, and is not identified as an “excluded person” by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare.
  • No history of a major disciplinary or legal action by a state medical board.
Benefits
  • Comprehensive benefits (including health insurance benefits)
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
Utilization ReviewClinical Quality ImprovementCare ManagementEvidence-Based MedicineMedical Policy DesignRisk ManagementClaim AdjudicationPharmacy ManagementPopulation Health ProgramsMedical Appropriateness Evaluation
Soft Skills
Interpersonal SkillsVerbal CommunicationWritten CommunicationTeam PlayerTeam BuilderLeadershipGuidance and InterpretationAbility to Navigate Corporate Matrix
Certifications
Board CertificationActive Physician License