Medical Director Utilization Management- Johns Hopkins Health Plans
1 day ago
POSITION SUMMARY
The Johns Hopkins Health Plans Medical Director is responsible for utilization management (UM) activities within JHHP’s four lines of business. The Medical Director renders medical necessity decisions on pre-service, concurrent, post-service, and appeals requests for the full range of healthcare services according to JHHP Medical Policy, plan sponsor regulation, and InterQual. They oversee clinical policy development via the Medical Policy Advisory Committee (MPAC) and facilitate collaboration across clinical areas.
In addition to UM activities, the Medical Director works with cross-functional teams to develop, implement, and measure clinical improvement activities. They serve as Subject Matter Experts to clinical and non-clinical staff across the organization and serve on Committees as a clinical expert. Additionally, the Medical Director heads performance improvement initiatives and serves as a thought leader for the organization.
REPORTING RELATIONSHIPS
The Medical Director of Johns Hopkins Health Plans reports directly to the ACMO, Medical Management of Johns Hopkins Health Plans.
POSITION RESPONSIBILITIES
- Reviews requests and appeals for inpatient care, skilled nursing facility stays, acute rehabilitation, outpatient services and procedures, pharmaceuticals, and durable medical equipment (DME). Applies appropriate policies, guidelines, or regulatory directives to make sound medical necessity decisions.
- Participates in, develops, and leads clinical initiatives aimed at improving members' health outcomes.
- Serves as a clinical expert on committees.
- Collaborates with other departments on projects to enhance clinical quality, operational efficiency, and financial performance.
- Acts as a preceptor for medical residents and administrative fellows, providing clinical and health plan guidance.
EDUCATION & WORK EXPERIENCE
- Requires a Medical Degree from an accredited Medical School.
- Unrestricted license as M.D./ D.O, licensed in Maryland.
- Experience with government payers (Medicaid, Medicare) preferred.
- Must have a minimum of 5 years of health plan experience and 5 years of clinical practice experience.
- Must be able to utilize multiple software programs and understand patient data reports, utilization reports and measure and assess outcomes.
- Experience with Emergency Department Sudden and Serious/Prudent Layperson review is strongly preferred.
- Experience with health plan Payment Integrity functions is strongly preferred.
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Hanover, MD, United States Johns Hopkins Health Plans Full timePOSITION SUMMARY The Johns Hopkins Health Plans Medical Director is responsible for utilization management (UM) activities within JHHP’s four lines of business. The Medical Director renders medical necessity decisions on pre-service, concurrent, post-service, and appeals requests for the full range of healthcare services according to JHHP Medical Policy,...
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