Medical Director - Utilization Management

The Medical Director, Utilization Management is responsible for assuring physician commitment and delivery of comprehensive high-quality health care to UPMC Health Plan members. This fully remote role will be responsible for assuring physician commitment and delivery of comprehensive high quality health care to UPMC Health Plan members. Oversees adherence to quality and utilization standards through committee delegations, and further establishes an effective working relationship between UPMC Health Plan's Network and its physicians, hospitals and other providers.

UPMC offers a premier benefits package, designed to care for your total well-being — physically, emotionally, and financially — paired with endless opportunities for career advancement and growth.  Discover the culture, the teams, and the passions that drive us to make Life Changing Medicine happen.

Responsibilities:

• Actively participates in the daily utilization management and quality improvement review processes, including concurrent, prospective and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns.
• Provide expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan.
• Keep current with accepted standards and professional developments in the areas of quality improvement and utilization management.
• Communicate and educate network providers regarding clinical guidelines, pathways, protocols, and standards related to quality and utilization processes.
• Interacts with physicians regarding opportunities to improve member satisfaction and compliance with Utilization Management and Quality Improvement policies and procedures.
• Contributes to process improvement within the Utilization Management department.
• Participates in activities to support policy decision making. 
• Utilizes clinical experience to support departmental reviews.