What are the responsibilities and job description for the Medical Director position at Hanover?
Associated Care Ventures Overview
Associated Care Ventures, Inc. (ACV) is the Birmingham-based parent company of Simpra Advantage, Inc., an Alabama-domiciled insurance company operating an Institutional Special Needs Plan, a Dual Eligible Special Needs Plan, and an Institutional Equivalent Special Needs Plan. ACV is the parent company of Alabama Select Network, LLC, which is operating an Integrated Care Network for the Alabama Medicaid Agency, to coordinate Medicare and Medicaid services state-wide for eligible individuals receiving long-term services and supports, both living at home and in nursing facilities.
Position Summary
The Medical Director, Utilization Management (UM) serves as the physician leader responsible for medical necessity determinations, utilization review activities, appeals, and clinical oversight of the health plan's medical management programs. This position provides physician leadership for inpatient, observation, post-acute, and outpatient utilization management activities to ensure high-quality, cost-effective, and evidence-based care for members.
The Medical Director collaborates closely with nursing UM staff, care management, network providers, quality teams, and executive leadership to improve clinical outcomes, reduce avoidable utilization, and ensure compliance with CMS, NCQA, state, and accreditation requirements.
This role is particularly responsible for building and overseeing the plan's inpatient and outpatient auth requests and observation review processes for a high-risk Special Needs Plan population.
Essential Duties and Responsibilities
Utilization Management Leadership
- Provide physician oversight of all utilization management activities.
- Perform medical necessity reviews for inpatient, observation, outpatient, SNF, Skill in place, and post-acute services.
- Conduct Level II physician reviews and issue adverse determinations when appropriate.
- Provide guidance regarding application of:
- CMS regulations
- Interqual Criteria
- National and Local Coverage Determinations
- Health plan medical policies.
Inpatient & Observation Management
- Develop and implement inpatient and observation review programs.
- Review inpatient admissions for appropriateness of level of care.
- Identify opportunities to:
- Reduce avoidable admissions
- Reduce observation overutilization
- Improve discharge planning
- Prevent readmissions.
- Partner with hospitals and facilities to optimize transitions of care.
Peer-to-Peer Reviews
- Conduct peer-to-peer discussions with treating physicians.
- Participate in provider education regarding medical necessity requirements.
- Resolve authorization disputes and escalation cases.
Appeals & Grievances
- Serve as physician reviewer for appeals and reconsiderations.
- Support external review preparation.
- Ensure regulatory turnaround times are met.
Clinical Program Development
- Collaborate with care management and quality teams to develop:
- Clinical pathways
- High-risk member interventions
- Facility-based management programs
- Utilization reduction initiatives.
Data Analytics & Performance Improvement
- Review utilization trends and identify opportunities for improvement.
- Analyze:
- Admission rates
- Observation rates
- Readmissions
- ER utilization
- Denial rates
- SNF utilization.
- Participate in development of predictive models for high-risk populations.
Regulatory & Accreditation Compliance
- Ensure compliance with:
- CMS Medicare Advantage regulations
- NCQA UM standards
- State regulations
- Delegation oversight requirements.
- Participate in audits and regulatory examinations.
Care Program Participation
Serve as physician lead or member for:
- Utilization Management Committee
- Quality Improvement
- Readmission Reduction
- Clinical Policy
Supervisory Responsibilities
Provides physician leadership and clinical oversight for:
- UM Nurse Managers
- UM Nurses
- Appeals Nurses
- Clinical Pharmacists (matrix relationship)
Additional responsibilities as deemed necessary
Minimum Qualifications
Education
- MD or DO degree from accredited medical school.
Licensure
- Current unrestricted Alabama medical license.
- Ability to obtain additional state licenses as needed.
Board Certification
Board Certified in one of the following:
- Internal Medicine
- Family Medicine
- Geriatrics
- Physical Medicine & Rehabilitation
- Emergency Medicine
Experience
Required:
- Minimum 5 years clinical practice experience.
- Minimum 3 years managed care experience.
- Minimum 2 years utilization management experience.
Preferred:
- Medicare Advantage experience.
- ISNP, DSNP, PACE, or long-term care experience.
- Experience managing inpatient and observation programs.
- Experience with high-risk geriatric populations.
Knowledge, Skills & Abilities
- Strong understanding of Medicare Advantage regulations.
- Knowledge of MCG/InterQual criteria.
- Expertise in inpatient utilization management.
- Knowledge of long-term care and post-acute care delivery systems.
- Strong analytical skills and data interpretation.
- Excellent physician communication and negotiation skills.
- Ability to function effectively in a matrix organization.
- Strong executive presentation skills.