Associate Medical Director - Managed Care, Utilization Management

Description We’re searching for an Associate Medical Director - Managed Care, Utilization Management, someone who’s ready to be part of the best ranked children’s hospital in Texas, and among the best in the nation. In this position, you will be responsible for establishing health plans and medical policies. The Associate Medical Director provides guidance to areas within departments of the Texas Children's Health Plan (TCHP); oversees assigned functions of the health plan; provides support, education, and consultation to Texas Children's System staff and physicians, regarding resource utilization, managed care and continuity of care issues. Think you’ve got what it takes? Job Duties & Responsibilities Working with the CMOs and Medical Directors, you will oversee and provide recommendations to continuously improve the implementation of medical management programs as outlined in the policy and procedures. The programs include discharge planning; case and referral management; and the use of clinical protocols and medical review criteria. Working with the CMOs provides input into the development of standards for behavioral health care, practice guidelines, and medication management. Oversees the clinical professional review of behavioral health care by the registered nurses employed by the Health Plan and ensures regulatory compliance. 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. Completes medical necessity reviews and appeals of requests for medical care based upon evidence-based guidelines approved by the CAAC, using appropriate independent clinical judgment and not adversely influenced by fiscal management decisions. Documents denials of services not meeting medical necessity. Ensures that the UM Program reflects current philosophies in managed care and the stated values and goals of Texas Children’s. Working with the CMOs, develops guidelines and ensures office sites and medical records meet the standards for proper behavioral health care. Educates providers, as necessary. Supervises the use of physician profiles and educates the providers in the interpretation of these profiles. Using data obtained through encounter and claims information, and electronic medical records from the group practices and hospital, monitors outcomes of members. This function is also done in conjunction with the CMOs, Medical Affairs Office and the Quality and Outcomes Management Department. Identifies strategies to affect outcomes. Regulatory compliance and compliance with accreditation agencies –such as NCQA and TDI. Works with personnel in exceeding requirement of federal, state and accreditation agencies, and prepares for inspection and reviews by the above agencies. Participate in other Committees as directed by the CMO’s affecting patient care and medical policy, teaching programs and consults on managed care as necessary. Interacts with and participates in committees and medical functions of outside agencies to include primary HMOs, state and federal agencies, and professiona