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Texas Health Resources Medical Director-Utilization Management-Southwestern Health Resources in Farmers Branch, Texas

Southwestern Health Resources Clinically Integrated Network (SWHR CIN), is hiring for a Medical Director-Utilization Management.

The Medical Director will act as the primary medical resource, within Utilization Management (UM), to keep patients safe, improve quality, and combat fraud, waste and abuse. The Medical Director will perform timely physician level reviews for medical necessity determinations, quality evaluation, and other utilization management evaluation as needed. The Medical Director will leverage UM program detail, Health Plan information, and other tools to provide individualized analysis to providers and facilities and suggest program development or modification within Utilization Management (UM) to improve member outcomes. The Medical Director will maintain a consistent high level of service and effective relationships with the UM Department staff, physicians, hospitals and medical service companies. The incumbent is accountable for quality and value management of all product lines and services.

Location: Farmers Branch

Core Hours

• Full time, Monday through Friday, 8am-5pm

Job Duties

Assists with oversight of clinical decision making aspects of the UM program, with the goals of keeping patients safe, improving quality of care, and enhancing affordability of care.

Reviews and decides UM cases, reducing waste, ensuring that all requests for services and resources meet medical necessity criteria, and are medically prudent.

Participates in peer to peer discussions with physicians requesting pre-certifications/ authorizations or other medical necessity determinations.

Provides guidance for clinical operational aspects of the program.

Actively participates/ facilitates Quality and Utilization Management Committees.

Participates in setting policies and procedures for the Utilization Management department.

Collaborates with internal and external entities to improve accessibility standards and quality practice standards to enhance value across the service delivery system (inpatient, emergency departments, urgent care services and practitioner office settings).

Maintains a mutually professional relationship with physicians, hospital personnel, social services, agencies, etc.

Assists in ensuring that Utilization Management Program policies and procedures meet regulatory requirements. Maintains relationships with key leaders and works to support their business strategies. Is accountable for the overall quality and affordability of care of the clinical programs and processes in concert with the VP of Expense Management.

Is responsible for compliance with the policies and procedures, the standards of accrediting bodies and the regulations of state and local governing agencies.

Is accountable for clinical excellence in providing managed care services that focus on quality patient care, timely provision of services, and cost-effectiveness.

Comply with all compliance, regulatory and process training within the specified timeline.

Education

M.D. or D.O. required

Experience

5 years general medical clinic practicing physician required

2 years utilization management experience including MA medical review, peer to peer, and physician/ facility liaison functions preferred

Licenses and Certifications

MD - Medical Doctor State of Texas, or, DO - Doctor of Osteopathic Medicine State of Texas required upon hire.

American Board of Medical Specialty Certification in respective area required upon hire

Skills

Strong analytical and organizational skills.

Knowledge of Medicare, Medicaid, and Commercial Coverage Criteria

Knowledge of specific regulatory and managed care requirements

Southwestern Health Resources (SWHR) is a patient-centered clinically integrated network of 29 hospital locations and more than 5,500 physicians and other clinicians. Formed by Texas Health and UT Southwestern, two of the region’s leading healthcare systems, SWHR delivers nationally preeminent, highest-quality care in 16 counties across North Texas. SWHR is also the parent organization of Care N’ Care Insurance Co., a regional Medicare Advantage Plan serving more than 13,500 members in the region.

The SWHR network includes physicians from UT Southwestern and Texas Health, and independent community primary care and specialty physicians. In partnership, our team implements physician-driven, value-based care strategies to coordinate care for more than 700,000 patients, resulting in lower costs and high-quality care. In 2020, the Centers for Medicare & Medicaid Services released the annual financial and quality results and, based on the report, SWHR is one of the nation’s leading Next Generation Accountable Care Organizations, having saved nearly $120 million since joining the program in 2017.

At the heart of SWHR are people who help people. We care about those we serve and each other. To be the national leader in providing population-based healthcare, our more than 850 employees use their knowledge, data insights and clinical experience to deliver care to the right patient, at the right time and in the right setting. By connecting physicians to patients and clinical insights to better outcomes, SWHR lowers costs, optimizes value, and builds a better healthcare system for all.

We invite you to learn more about us at www.southwesternhealth.org.

Let’s move healthcare forward – together.

Employment opportunities are only reflective of wholly owned Texas Health Resources entities.

We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

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