Family Medicine Medical Director Utilization Management

AmeriHealth Caritas is a mission-driven healthcare organization headquartered in Newtown Square, Pennsylvania, with over 30 years of experience in delivering comprehensive, outcomes-driven care to underserved populations. As a nationally recognized leader in health care solutions, AmeriHealth Caritas focuses on helping people get care, stay well, and build healthy communities. The company offers a wide range of services including integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and various administrative supports. AmeriHealth Caritas is committed to creating healthier communities through innovative and effective healthcare programs, supported by a team of passionate professionals dedicated to making a positive impact on the lives of millions across its national footprint.

The role of Medical Director, Utilization Management (UM) at AmeriHealth Caritas is a critical leadership position tasked with overseeing key operational areas within the UM program. This includes prospective, concurrent, and retrospective reviews that ensure patient care decisions and referrals are medically appropriate according to national and local criteria. As a Medical Director in UM, you will play a vital role in the development and implementation of medical policies, procedures, and clinical guidelines that meet both contractual obligations and regulatory standards. This role involves partnership with Quality Improvement teams to analyze utilization trends and design interventions to enhance clinical effectiveness and overall health management.

Serving as a medical advisor and manager, you will provide clinical oversight and guidance on all medically related activities, ensuring that the organization’s practices adhere to established regulations and policies. You will conduct clinical case reviews collaboratively with the Medical Excellence Department, demonstrating a strong understanding of medical procedures and practices. This role also requires familiarity with federal, state, and local clinical operations regulations and includes responsibility for leadership in medical policy development related to health management and compliance.

In your day-to-day activities, you will manage the integration and processing of members, optimizing the use of behavioral and physical health services. Collaboration is central to this role as you will work closely with a multidisciplinary team, including Corporate Medical Directors, Utilization and Case Management RNs, and other staff, to ensure clinical programs meet contractual and quality standards. You will frequently engage in peer-to-peer discussions with physicians and providers to foster collaborative care and resolve clinical issues.

The role requires participation in quality improvement initiatives, including identifying and analyzing medical and behavioral health data to create strategies that improve clinical effectiveness. You will also focus on staff development, training clinical teams on key medical issues, and supporting care managers by assessing members’ needs and attending relevant case management meetings. Thorough documentation of all care coordination activities in electronic medical records is essential.

This position is fully remote, offering flexible work arrangements with the expectation to work rotational weekends and holidays. AmeriHealth Caritas provides a competitive salary and a comprehensive benefits package designed to support a healthy work-life balance and professional growth. This role demands a strong medical background, leadership skills, and a commitment to advancing healthcare quality in a dynamic environment, making it an exceptional opportunity for healthcare professionals passionate about making a difference in managed care.