We are searching for a Medical Director of Utilization Management - The Health Plan - someone who works well in a fast-paced setting. In this position, you will be responsible for establishing health plan medical policies, guidelines, and review criteria. The Medical Director provides: guidance to areas within departments of Texas Children’s Health Plan (TCHP); oversees assigned functions of the health plan, provides support, education and consultation to Texas Children’s system staff and physicians regarding resource utilization, managed care and population health management. Works in coordination with Director of Utilization Management to ensure appropriate analysis and implementation of medical policy.
Think you’ve got what it takes?
Provides leadership in the development, direction, execution, and evaluation of an effective utilization management program that supports the delivery of quality healthcare in the most appropriate and effective manner, meeting the obligations of contractual and regulatory requirements
Working with the CMOs and Director for Utilization Management, leads development of medical review criteria for utilization of medical and behavioral health services
Contributes to policies and procedures for utilization management which are consistent with the TMPPM, UMCC and TDI rules.
Oversees the Associate Medical Directors in Utilization Management and works with the Director of UM to coordinate departmental functions with Business Operations, Claims Administration, Care Management, Contracting, Information Systems, Member Services, Finance, and the TCH Integrated Delivery System
Coordinates training of Associate Medical Directors and external vendors to ensure a comprehensive, up-to-date knowledge base for medical and behavioral health reviews
Partners intentionally and strategically with medical leadership across the organization, leveraging data to drive decision making, in order to ensure consistent execution of utilization management vision across entities
Participates in other TCHP Committees affecting patient care and medical policy, Baylor teaching programs and consults on managed care as necessary
Doctor of Medicine (M.D.) required
MDL from the Texas Medical Board required in addition to one of the following:
BCP certification from the American Board of Pediatrics
BCFM certification from the American Board of Family Medicine
BCPP certification from the American Board of Psychiatry & Neurology
BCOBGYN certification from the American Board of Obstetrics & Gynecology
5 years of healthcare management, managed care experience, and/or behavioral health experience required
Work history experience in a Managed Care Organization (MCO) required.
Internal Number: TCHP
About Texas Children's Health Plan
Texas Children’s Health Plan was founded in 1996 by Texas Children’s Hospital. We are the nation's first health maintenance organization (HMO) created just for children. We cover kids, teens, pregnant women, and adults. If you are able to get Medicaid or the Children’s Health Insurance Program (CHIP), we have a large group of more than 4,300 doctors, 6,800 specialists, 118 hospitals, and health resources to care for your needs.