Job Description

Medical Director Physician at UPMC summary:

The Medical Director, Grievances at UPMC Health Plan is a board-certified physician responsible for overseeing quality and utilization management within the health plan. This remote, part-time role involves leading provider credentialing, managing grievance hearings, and ensuring compliance with clinical and regulatory standards. The Medical Director also collaborates with network providers and public health authorities to improve member outcomes and support quality improvement initiatives.

The UPMC Health Plan is seeking a board-certified physician with a Pennsylvania Medical License for a Medical Director, Grievances role with UPMC Community Health Choices. This role is fully remote and will require 10-18 hours per week between 8am - 4pm EST, in order to attend grievance hearings. One of the perks of this position is that the selected candidate will be able to choose their weekly availability within the aforementioned time frame.

The Medical Director, Grievances is responsible for assuring physician commitment and delivery of comprehensive high quality health care to UPMC Health Plan members. They oversee adherence to quality and utilization standards through committee delegations and further establish an effective working relationship between the UPMC Health Plan's Network and its physicians, hospitals, and other providers.

Responsibilities:

• Provide leadership direction for provider credentialing processes.
• Physicians must devote sufficient time to the CHC-MCO to provide timely medical decisions, including after-hours consultation, as needed
• Provide leadership and direction in meeting Quality Improvement and Care Management goals directed at improvements in member health status outcomes and established business strategies.
• Provide expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan.
• Actively participates in the daily utilization management and quality improvement review processes, including concurrent, prospective and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns.
• Keep current with accepted standards and professional developments in the areas of quality improvement and utilization management.
• Communicate and educate network providers regarding clinical guidelines, pathways, protocols, and standards related to quality and utilization processes.
• Responsible for reporting the communication of reportable communicable diseases in accordance with statute.
• Interacts with physicians regarding opportunities to improve member satisfaction and compliance with Utilization Management and Quality Improvement policies and procedures.
• Work with the DOH State and District Office Epidemiologists in partnership with the designated county/municipal health department staff to appropriately report reportable conditions in accordance with 28 Pa. Code 27.1 et seq.
• Daily interventions support implementation of the Health Plan's Quality Improvement and Care Management Programs.
• Represent the Health Plan in external accreditation and certification activities.
• Act as first level physician reviewer for all cases referred by the Quality Improvement and Care Management Departments.
• Daily activities support adherence to quality and utilization standards and establish an effective working relationship between UPMC Health Plan's Network and its physicians, hospitals and other providers.

Qualifications:

Doctor of Medicine or Doctor of Osteopathy from an accredited school.

Licensure, Certifications, and Clearances:

• Doctor of Medicine (MD) OR Doctor of Osteopathic Medicine (DO)
• Pennsylvania Medical License

UPMC is an Equal Opportunity Employer/Disability/Veteran

Keywords:

medical director, physician leadership, quality improvement, utilization management, provider credentialing, grievance hearings, healthcare compliance, network provider collaboration, medical review, health plan management

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