National Medical Director Utilization Management - Quality Management
Company: Hybridge Staffing
Location: Las Vegas
Posted on: January 24, 2023
Medical Director opening in Las Vegas, Nevada. This and other
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National Medical Director Utilization Management – Quality
*Can work remote
*Excellent compensation package and full benefits
- Leads, develops, directs, and implements clinical and
non-clinical activities that impact health care quality cost and
- Identifies and develops opportunities for innovation to
increase effectiveness and quality.
- Provide clinical expertise across the enterprise for various
- Responsible for corporate and medical policy interpretation,
recommendation, and review within recognized areas of
- Advise and collaborate in the develop of clinical
- Provide clinical support and participate in utilization
management, quality management and care management programs in
respective area and identify opportunities for improvement and
- Assist with the design, development, implementation and
assessment of preventative care, quality, and health enhancement
programs that support the appropriate use of clinical resources in
the delivery of consistent high- quality medical care to drive
HEDIS metric compliance.
- Provide clinical leadership for medical necessity reviews,
application of clinical guidelines in decision making and for
health promotion and education programs
- Assist is establishing corporate and regional programs to
enhance quality of care reduce medical costs and achieve positive
- Serves as a clinical resource and subject matter expert to both
clinical and non – clinical staff.
- Perform clinical reviews and conduct peer to peers.
- Conduct discussions with physicians in the network regarding
HEDIS metrics, medical policies, utilization management, claims
editing, use of resources and quality.
- Perform clinical data review of HEDIS compliance and develop
strategic initiatives to increase patient compliance.
- Perform high dollar claims and complex case reviews.
- Participate in inter-rater reliability activities.
- Participate in committees and workgroups to achieve department
and corporate objectives.
- Participate in health plan Joint Operating Committees.
- Doctorate from an accredited school of medicine (M.D.) or
osteopathy (D.O.) required.
- Seven (7) years of clinical experience or any combination of
education and experience, which would provide an equivalent
- Two (2) years of previous medical director experience working
for a health plan, medical group, or hospital in a utilization
management, quality management or medical management
- Current unrestricted state of Nevada, Arizona, Oregon, Doctor
of Medicine (M.D.) or Doctor of Osteopathy (D.O.) license or
ability to obtain license.
- Board certified or board eligible and working towards
certification in a specialty approved by the
- American Board of Medical Specialists or the American Board of
- Certification in Utilization Review and Health Care Quality &
Management is preferred.
- Knowledge of HEDIS, NCQA, and CMS Stars Programs
- Ability to effectively communication with external physicians
- Proven leadership, problem solving and the ability to manage
- Requires strong oral, written and interpersonal communication
skills, problem-solving skills, facilitation skills, and analytical
- Results oriented and the ability to take ownership for
initiatives and collaborate with cross-functional teams to achieve
department and corporate goals.
- Demonstrate skill with Microsoft Office Suite and web-based
- Understanding of health plan and medical group functions
related to utilization, care, as well as HEDIS/STAR s and NCQA.
Familiarity with CMS regulations and standards.
- Basic knowledge of evidence-based clinical decision support
guidelines (Inter Qual/Milliman).
- Basic knowledge of CPT coding and guidelines and how they
relate to quality data capture.
- Other related skills and/or abilities may be required to
perform this job.
To apply and learn more about this position please email a copy of
your cv to
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Keywords: Hybridge Staffing, Las Vegas , National Medical Director Utilization Management - Quality Management, Executive , Las Vegas, Nevada
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