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Healthcare Leader
2 semanas atrás
Unlocking High-Quality Care
This key leadership role is designed for a skilled physician who thrives in a dynamic, data-driven environment and is passionate about transforming healthcare delivery.
The ideal candidate will provide clinical oversight and strategic guidance to ensure members receive high-quality, medically appropriate care. This critical role bridges clinical expertise with operational execution across various care models.
- Key Responsibilities:
- Review and issue timely determinations for prior authorization requests, ensuring medical necessity and regulatory compliance.
- Collaborate with teams to streamline and enhance prior authorization workflows for efficiency and provider satisfaction.
- Provide clinical leadership in the development and implementation of authorization criteria and policies based on the latest medical standards.
- Communicate authorization decisions clearly to providers and members, including rationale and guidance for alternative treatment options when applicable.
- Job Requirements:
- Medical Degree (MD or DO) from an accredited institution; active and unrestricted medical license.
- Board certification (preferred) in a relevant specialty.
- Minimum 5+ years of clinical practice experience.
- At least 3 years of experience in utilization management or medical management within a health plan or risk-bearing organization.
- Deep knowledge of managed care, value-based care, and CMS guidelines.
- Proficient in applying evidence-based criteria.
- Strong understanding of state and federal regulations.
What You'll Gain:
As a valued member of our team, you will have opportunities to develop your clinical skills, collaborate with interdisciplinary teams, and contribute to improving healthcare equity, quality, and cost-effectiveness.
