Stanford Health Care
Medical Director, Utilization Management Opportunity
University Medical Partners, Inc.
The UM Medical Director is a part-time management position at the Accountable Care Operating Division of Stanford Health Care’s community-based medical foundation, UHA. Working closely with the CMO Accountable Care and Management, the Medical Director will serve as the physician manager responsible for oversight of the clinical services provided at the Operating Division and delegated to UHA by payors. Specifically, the Medical Director will provide the regulatory and contractual clinical oversight of authorizations for care, quality of care, and utilization/cost management of population-based risk arrangements, including Commercial HMO and Medicare Advantage HMO. Under direction of the CMO Accountable Care, serves as the physician lead with other Accountable Care departments and teams, such as Network Management, Provider & Member Services, Claims Management, and Finance & Analysis. Assists in short and long-range program planning, process improvement, and management of Accountable Care Division. Monitors all issues of clinical quality in the Operating Division. Provides analysis and reporting on Accountable Care clinical performance.
- Provide Clinical Oversight for the Utilization Management Functions
- Provide medical direction and drives quality and process improvement efforts for the functions and activities related to the authorization of eligible medical services, referral authorization activities, and referral authorization staff.
- Supports pre-admission review, utilization management, and concurrent and retrospective review process/
- Actively interfaces with providers (hospitals, SNFs, Hospitalist) to improve health care outcomes, health care service utilization and costs.
- Leads and/or supports resolution of member or provider grievances and appeals.
- Participates in policy review, performs analysis, and develops recommendations that support the design and implementation of medical policies in support of appropriate UM goals and objectives
- Provides periodic written and verbal reports and updates regarding Utilization Management functions and programs as required in Quality Management Program descriptions and Annual Work Plans.
- Assures compliance with legal and regulatory requirements, including Federal (e.g., CMS), State (e.g., DMHC) and local rules and regulations. Provides timely Management to the Department to meet UHA meet UHA objectives to provide excellent high-value patient care for the populations under risk contracts.
- Works closely with the Director of Utilization Management and Director of Quality to assure that UHA maintains top performance in Population Health.
- Services as interfaces point and clinical support to internal and external (e.g. health plan) care management teams to drive improved patient outcomes.
- Serve as a point of escalation for all Utilization Management functions and related processes.
- Serve as Clinical Leader to Internal and External Constituents
- Develop, maintain and grow relationships with key participating providers and personnel across the network to educate and influence behaviors that drive improvements in utilization management and adoption of evidence-based medicine practices.
- Represent the organization as a clinical leader in meetings with health plans, regulatory bodies, and other organization business partners and affiliates.
- Member of various UHA committees including Credentialing, Quality, and Accountable Care.
- Participate in and assist in facilitating various leadership and management forums, such as strategic planning and operational management meetings.
- Engage in clinical initiatives and support fellow Medical Directors in support of other Stanford Health Care related accountable care programs (e.g. Stanford Health Care Alliance, Stanford Health Care Advantage).
- Interface with internal teams, including but not limited to Clinical Quality, Provider Network Management, Digital Solutions, and Decision Support to drive improved clinical outcomes via network design changes, provider education initiatives, etc.
- Analyze Performance & Development Programs to Drive Improvement
- Participates in the review and analysis of performance from summary data of paid claims, encounters, authorization logs, and other available sources to analyze quality, utilization, and cost management performance and identify opportunities for improvement.
- Assist in the design, implement, and oversight of care management programs and interventions to drive improved performance in utilization, cost, quality, and network design.
- Familiarity with Epic EMR a plus.
All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, protected veteran status, or disability status.