Daily utilization management activities for all lines of business including Medicare. Assist in the recruitment of participating providers, support provider relations activities, monitor performance of participating physicians and assist in the development and implementation of medical policy. Participate in the attainment of quality management goals to meet or exceed quality standards as established by all external agencies. Participate in the identification and analysis of medical information from multiple sources in order to develop interventions to improve the quality of care and outcomes.
Manages all major clinical and quality program components of the health plan. Ensures timely medical decisions, including after-hours consultation as needed. Provides supervision and ensures sufficiency of the health plan provider network. Ensures compliance with State and local reporting laws on communicable diseases, child abuse, neglect, etc.
Reports to: Chief Med Director – Medical Management
Department: BH-Behavioral Health
Location: Tampa (Henderson Rd) or Remote
- Supervise, review and approve or deny requests for medical necessity decisions according to medical policy.
- Interpret medical policy criteria for Health Services associates to facilitate the application of policy in pre-certification, concurrent review and case management.
- Initiate dialogue with providers, as necessary, to resolve differences in opinions concerning utilization management. Review and make decisions on provider appeals.
- Make recommendations (based on daily activities of evaluating members' care) about medical policy, clinical criteria and administrative process.
- Serve on various committees to evaluate recommendations for changes.
- Work with the medical community to assist in the development and maintenance of a strong, quality network of providers.
- Support provider relations and risk contracting through education, provider visits and problem resolution.
- Visit targeted providers for recruitment, as well as performing proactive provider visits as scheduled.
- Work with quality management and medical cost analysis staff to identify trends in treatment and outcomes by interpreting various data.
- Review provider and member complaints, assist in resolution, and make recommendations for changes.
- Utilize clinical expertise to assist in the development of care improvement programs to improve health outcomes for the member population.
- Manages and develops direct reports who include directors and/or managers