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Define Ventures Partners

Medical Director, Utilization Management Operations

Cohere Health

Cohere Health

This job is no longer accepting applications

See open jobs at Cohere Health.
United States
Posted on Friday, January 26, 2024

Medical Director, Utilization Management Operations


Company Overview

Cohere Health is illuminating healthcare for patients, their doctors, and all those who are important in a patient’s healthcare experience, both in and out of the doctors office. Founded in August, 2019, we are obsessed with eliminating wasteful friction patients and doctors experience in areas that have nothing to do with health and treatment, particularly for diagnoses that require expensive procedures or medications. To that end, we build software that is expressly designed to ensure the appropriate plan of care is understood and expeditiously approved, so that patients and doctors can focus on health, rather than payment or administrative hassles.

Opportunity overview

We are looking for a Medical Director, Utilization Management Operations who will lead our Medical Review clinicians by supporting clinical program and guideline design, serving as an expert escalation point for the clinical operations physician and nursing staff, and serve as a physician representative of the company in interactions with our physician end-users. You will need experience leading medical teams in an operational setting. This is a collaborative cross functional role that will provide clarity in a growing, complex organizational environment, generate energy through a bias towards action, and deliver results. This is a permanent remote, full-time position with overall responsibilities of daily business operations.

What you will do:

  • Lead a team of Associate Medical Directors responsible for prior authorization clinical reviews and Peer to Peer discussions
  • Experience in Diagnostic Imaging, Endoscopy and Sleep Medicine preferred
  • Inspiring and motivating team members to perform at their best
  • Identifying potential problems and points of friction and working to find solutions in order to maximize efficiency and revenue
  • Develop and document standard operating procedures
  • Proven experience managing a remote workforce and operating efficiently in a virtual environment
  • Demonstrated ability in the construction and sustaining of stable clinical teams (clinician, nurse, and LPN)
  • Work cross functionally with VP, Physician Operations on workflow and process improvements
  • Support the clinical guidelines team in developing and reviewing the company’s clinical decision guidelines in conjunction with client guidelines and directives
  • Maintain awareness of any changes in the literature, standard of care, or regulatory guidance impacting the criteria by which the company reviews service requests
  • Provides timely expert medical review for requests to evaluate the medical necessity of services that do not meet utilization review criteria while located in a state or territory of the United States.
  • Perform timely review of Medical Coverage Policies for our clients
  • Performs clinical reviews on a daily and weekly basis
  • Reviews appeals for denied services related to current relevant medical experience or knowledge in accordance with appeal policies, if so delegated.
  • Provides timely peer-to-peer discussions when necessary with referring physicians to clarify clinical information and to explain review outcome decisions.
  • Documents all actions related to clinical review sessions and attests to appeal review qualifications as required.
  • Maintains necessary credentials and immediately informs Cohere of any adverse actions relating to medical licenses and/or board certifications.
  • Perform other duties as assigned

Your background & requirements:

  • An M.D. or D.O. with a current, active, U.S. state medical license and board certified as recognized by the American Board of Medical Specialties (ABMS)
  • 5 or more years of direct clinical patient care experience, beyond residency/fellowship
  • 3 or more years of direct supervision/management experience, preferably in an utilization management organization within a Medicare, Commercial or Medicaid payor organization
  • Leadership skills in working with other clinicians, knowledge of the overall medical community
  • Knowledge of managed care principles, HMO and Risk Contracting arrangements.
  • Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual, LCD, NCD)
  • Experience with NCQA accreditation
  • Strong interpersonal, oral and written communication skills.
  • Comptent on a computer, proficient in google applications (ie; sheets, slides, docs, etc)
  • Proficient in using a Mac laptop computer, GSuite and Gmail, Microsoft Excel and Microsoft Word
  • Ability to work remotely telephonically and/or via video with clinical colleagues and other personnel

We can’t wait to learn more about you and meet you at Cohere Health!

Equal Opportunity Statement:

Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it’s personal.



This job is no longer accepting applications

See open jobs at Cohere Health.