Associate Medical Director - Utilization Management

 
Position: Associate Medical Director - Utilization Management

Job ID: 158243

Location: US-TX-Houston

Department: Utilization Mgmt - Admin

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 texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

Summary:

We are searching for an Associate Medical Director - Utilization Management -- someone who works well in a fast-paced setting. In this position, you will be responsible for establishing health plan medical policies. The Associate Medical Director provides guidance, oversees assigned functions of the health plan and provides support, education, and consultation to staff and physicians regarding resource utilization, managed care and continuity of care issues.  Primary role will be utilization management, prior authorizations and concurrent hospital review.

 

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Responsibilities :

  • Working with the CMOs and Medical Directors, oversees and provides recommendations to continuously improve the implementation of medical management programs as outlined in the policy and procedures
  • Working with the CMOs and Medical Director for Utilization Management, provides input into the development of medical care guidelines for utilization of behavioral health services
  • Approves medical care based upon guidelines set-up and approved by the CAAC, using appropriate independent clinical judgment, and not adversely influenced by fiscal management decisions
  • Supervises the use of physician profiles and educates the providers in the interpretation of these profiles
  • Works with personnel in exceeding requirement of federal, state and accreditation agencies, and prepares for inspection and reviews by the above agencies
  • Interacts with and participates in committees and medical functions of outside agencies to include primary HMOs, state and federal agencies, and professional organizations as directed by the CMOs
  • Collaborates with CMOs on establishing QI standards, and assures their implementation and use


Qualifications:

Being fully vaccinated against COVID-19 is required for all employees at Texas Children’s, unless approved for a medical or religious exemption.

  • Doctor of Medicine or Doctor of Osteopathic Medicine required
  • Medical License from the Texas Medical Board required
  • Board Certification in pediatrics, family medicine or obstetrics/gynecology required
  • 5 years healthcare management, managed care experience required


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