Medical Director, Utilization Management @Quantum Health

Overview

The role is for a Medical Director in Utilization Management at Quantum Health, a healthcare navigation organization. The candidate will be responsible for clinical oversight and support, focusing on optimizing healthcare services for members.

Key Responsibilities

• Serve as a key clinical resource for staff.
• Establish criteria and protocols for standard medical treatment inquiries and render determinations on requests for healthcare services.
• Conduct daily reviews of individual cases, including prior authorizations and denial decisions.
• Provide clear and concise documented medical review determinations and support on requested reviews.
• Identify opportunities to implement best practices approaches and introduce innovations to improve outcomes.
• Perform utilization review and case management support on complex members.
• Provide support for chronic disease management via phone, messaging, and video.
• Serve as a medical liaison to physicians, hospitals, and insurance carriers.
• Evaluate and interpret data to identify areas for improvement.
• Other duties as assigned.

Requirements

• Education: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• Board certification in primary specialty required.
• Minimum five (5) years of progressively responsible clinical practice experience.
• Minimum two (2) years of physician clinical review experience, preferably in a commercial health plan or utilization management.
• Strong written and verbal communication skills, including clear clinical documentation.
• Collaborative, team-oriented mindset with the ability to work effectively across disciplines.
• Knowledge of the U.S. healthcare delivery system and utilization management principles.
• Accountability to protect company and member data by adhering to organizational ethics, privacy, and security policies.

Benefits

Information on benefits was not provided in the listing.

Location

Remote position with hybrid flexibility; the primary campus is in Dublin, OH.

How to Apply

Details on how to apply were not provided in the listing.