Medical Director - Utilization Management - The Health Plan

Position: Medical Director - Utilization Management - The Health Plan

Job ID: 154362

Location: US-TX-Houston

Department: Medical Affairs

Talent Area: Physician

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a-5p

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 14,000+ dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at


We are searching for a Medical Director -- someone who works well in a fast-paced setting. In this position, you will be responsible for establishing health plan medical policies. The Medical Director provides guidance to areas within departments and oversees assigned functions. This role also provides support, education, and consultation to staff and physicians regarding resource utilization, managed care, disease management and continuity of care issues.

Think you’ve got what it takes?

Responsibilities :

  • Oversees and provides recommendations to continuously improve the implementation of medical management programs as outlined in the policy and procedures
  • Develops of medical care guidelines for utilization of behavioral health services
  • Develops guidelines and ensures office sites and medical records meet the standards for proper behavioral health care
  • Works closely with Network management team to ensure accessibility for members to services as well as providing input to value-based contracts, incentive programs and other contracting opportunities
  • Ensures that approved medical protocols, rules of conduct and compliance with standards of public health are followed by medical staff and providers
  • Monitors outcomes of members
  • Participates in committees as directed by the CMOs affecting patient care and medical policy, Baylor teaching programs and consults on managed care as necessary
  • Provides direction and oversight to Associate Medical Directors or other direct reports


  • 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 or BCFM certification from the American Board of Family Medicine
  • 5 years of healthcare management, managed care experience, and/or behavioral health experience required

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