The Medical Director, Utilization Management, provides organizational leadership in the operational areas of appeals, utilization review, quality improvement, and related policy and practice initiatives in collaboration with the Corporate Medical Director(s), Utilization Management, and the Vice President, Medical Affairs. The following responsibilities are regarding enrollees with medical conditions and their providers: + Identifying and implementing evidence-based practice guidelines throughout the provider network. + Overseeing the quality of clinical care for network and non-network providers. + Engaging the provider network in Continuous Quality Improvement through the diffusion of practice standards and an internal quality assurance program that measures network provider performance against high-quality standards, especially the HEDIS program’s performance standards. + Ensuring a high-performing Medical Management system that adheres to the terms of contracts and all relevant regulatory requirements. + Utilizing evidence-based standards in making coverage determinations. **Work Arrangement:** + Full Time Remote with required evening, weekend, and holiday coverage. **Accountabilities:** + Ensures quality and clinically sound services for all enrollees through associates and providers. + Serves as medical advisor and manager for all clinically related activities. + Ensures that the organization’s medical policies and procedures adhere to contractual obligations. + Performs clinical case reviews in conjunction with the Medical Excellence Department. + Demonstrates knowledge of prescribed and established medical procedures and practices. + Maintains familiarity with federal, state, and local medical and clinical operations regulations. Provides leadership in developing and implementing medical policy related to health management, compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations. + Manages day-to-day operations and monitors the integration and processing of members to optimize the appropriate use of behavioral and physical health services. + Participates with Quality Improvement and Medical Excellence in identifying and analyzing medical and behavioral health information to develop interventions to improve the clinical effectiveness of medical management strategies. Work closely with a multidisciplinary team to ensure behavioral health management and quality management programs meet contractual obligations. + Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff. + Trains staff on medical issues and provides consultation to staff as appropriate. + Assists Care Managers in assessing members’ needs for case management services and attends meetings and monthly rounds as scheduled. + Collaborates with the integrated case management team during scheduled meetings and informally as needed + Thoroughly documents all care coordination activity in the member’s medical record in the electronic case management documentation system. **Education/Experience:** + MHA, MPH, or MBA in healthcare management preferred. + A minimum of three (3) years of utilization management or appeal experience in a Medicaid, Medicare, dual eligible, or commercial health plan is preferred. + A minimum of five (5 )years of clinical practice experience is required. + Proficiency utilizing MS Office (Word, Excel, Outlook), internet applications, and electronic medical record and documentation programs. **License Requirement:** + Doctor of Medicine (MD) or Doctor of Osteopathic Medicine licensed to practice as a medical director; additional state licensure required in all states where ACFC has a line of business, and that application is expected within 30 days of hire. + Current Pennsylvania license required, must be willing to obtain additional licenses where AmeriHealth Caritas has health plans. + Must be Board-certified in Family Medicine, Internal Medicine, or Emergency Medicine. Must be clear of any sanctions by the applicable state or the Office of the Inspector General. + Must not be prohibited from participating in any Federally or state-funded healthcare programs. **Other Skills:** + Strong written and oral communication skills are required. **Our Comprehensive Benefits Package** Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more. Your career starts now. We are looking for the next generation of health care leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you. Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com. As a company, we support internal diversity through: Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.