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National Medical Director Utilization Management - Quality Management (Physician )

Las Vegas, Nevada
Job Type
2 Sep 2022
Medical Director opening in Las Vegas, Nevada.

National Medical Director Utilization Management Quality Management

Can work remote
Growing organization
Excellent compensation package and full benefits

Job Description:

  • Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes.
  • Identifies and develops opportunities for innovation to increase effectiveness and quality.
  • Provide clinical expertise across the enterprise for various functions.
  • Responsible for corporate and medical policy interpretation, recommendation, and review within recognized areas of responsibility.
  • Advise and collaborate in the develop of clinical programs.
  • Provide clinical support and participate in utilization management, quality management and care management programs in respective area and identify opportunities for improvement and efficiency.
  • Assist with the design, development, implementation and assessment of preventative care, quality, and health enhancement programs that support the appropriate use of clinical resources in the delivery of consistent high- quality medical care to drive HEDIS metric compliance.
  • Provide clinical leadership for medical necessity reviews, application of clinical guidelines in decision making and for health promotion and education programs
  • Assist is establishing corporate and regional programs to enhance quality of care reduce medical costs and achieve positive health outcomes.
  • Serves as a clinical resource and subject matter expert to both clinical and non clinical staff.
  • Perform clinical reviews and conduct peer to peers.
  • Conduct discussions with physicians in the network regarding HEDIS metrics, medical policies, utilization management, claims editing, use of resources and quality.
  • Perform clinical data review of HEDIS compliance and develop strategic initiatives to increase patient compliance.
  • Perform high dollar claims and complex case reviews.
  • Participate in inter-rater reliability activities.
  • Participate in committees and workgroups to achieve department and corporate objectives.
  • Participate in health plan Joint Operating Committees.


  • Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O.) required.
  • Seven (7) years of clinical experience or any combination of education and experience, which would provide an equivalent background.
  • Two (2) years of previous medical director experience working for a health plan, medical group, or hospital in a utilization management, quality management or medical management preferred.
  • Current unrestricted state of Nevada, Arizona, Oregon, Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) license or ability to obtain license.
  • Board certified or board eligible and working towards certification in a specialty approved by the
    • American Board of Medical Specialists or the American Board of Osteopathy
  • Certification in Utilization Review and Health Care Quality & Management is preferred.
  • Knowledge of HEDIS, NCQA, and CMS Stars Programs
  • Ability to effectively communication with external physicians and organizations
  • Proven leadership, problem solving and the ability to manage multiple priorities.
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
  • Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.
  • Demonstrate skill with Microsoft Office Suite and web-based program.
  • Understanding of health plan and medical group functions related to utilization, care, as well as HEDIS/STAR s and NCQA. Familiarity with CMS regulations and standards.
  • Basic knowledge of evidence-based clinical decision support guidelines (Inter Qual/Milliman).
  • Basic knowledge of CPT coding and guidelines and how they relate to quality data capture.
  • Other related skills and/or abilities may be required to perform this job.
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  • Job Reference: 702688433-2
  • Date Posted: 2 September 2022
  • Recruiter: Hybridge Staffing
  • Location: Las Vegas, Nevada
  • Salary: On Application
  • Sector: Healthcare & Medical
  • Job Type: Permanent