Pacer Group
Director - Client Services, Recruitments & Operations
Shift:
8.00am - 5.00pm (Time Zone: EST, CST, PST) Location:
Remote Note: Flexible hours are being discussed to ensure coverage for weekends and holidays as required. Potential to work weekends only. Opportunities for Saturday and Sunday availability. Position Purpose: Collaborate with the Chief Medical Director to oversee medical management, quality improvement, and credentialing functions for the business unit. Responsibilities: Provide medical leadership in utilization management, cost containment, and quality improvement initiatives. Conduct medical review activities for utilization review, quality assurance, and complex cases, ensuring timely decision-making. Support the implementation of performance improvement initiatives for capitated providers. Assist in planning and setting goals to enhance the quality and cost-effectiveness of care for members. Supply medical expertise for utilization management and quality improvement programs in line with regulatory and accreditation standards. Help manage physician committees, including their structure, processes, and membership. Perform regular visits to assess and coordinate care for high-risk patients, collaborating with care management teams. Engage effectively with clinical teams, network providers, appeals teams, and consultants to review complex cases and necessity appeals. Participate in provider network development and market expansion as appropriate. Assist in developing and implementing physician education regarding clinical issues and policies. Evaluate utilization review studies to identify adverse trends and improve service quality. Identify quality improvement studies to mitigate unwarranted clinical practice variations, enhancing care quality and costs. Facilitate the implementation of recommendations aimed at improving utilization and healthcare quality. Review claims involving complex and controversial services to determine medical necessity and correctness of payment. Build relationships within the provider community through the implementation of medical management programs. May represent the business unit at various local and national forums on medical policies and issues as necessary. Join state committees and other ad hoc committees as needed. May work weekends and holidays to support business operations as required. Business Groups and Key Projects: Corporate Responsible for reviewing 12-15 UM decisions daily (inpatient, outpatient, Prior Authorization, etc.) Assess medical necessity against established guidelines. Conduct reviews through the EMR system (Client's system). Perform medical review activities for complex and experimental medical services to ensure quality and timely decisions. Helpful Backgrounds: UM experience (minimum of 1 year). Requirements: Medical Doctor or Doctor of Osteopathy required. Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association. Must Haves: For Behavioral Health only - Board certification by the American Board of Psychiatry and Neurology with an unrestrictive current state medical license. UM experience (minimum of 1 year). Able to obtain licensure in multiple states. Nice to Haves: UM experience. Not meeting the board certification. Performance Indicators: Production capacity around 12-15 cases daily. Quality of the review. A strong candidate would possess the following: Clinical Expertise:
Board-certified physician with active practice experience. UM Proficiency:
Proven ability to manage high-volume case reviews efficiently and accurately. Behavioral Health Experience:
Essential for psychiatry certification roles. Tech Savvy:
Comfortable with EMR systems and virtual collaboration. Adaptability:
Able to work independently in a remote setup while engaging with a dynamic team. Regulatory Knowledge:
Familiar with accreditation standards and state-specific requirements. Referrals can increase your chances of interviewing with Pacer Group.
8.00am - 5.00pm (Time Zone: EST, CST, PST) Location:
Remote Note: Flexible hours are being discussed to ensure coverage for weekends and holidays as required. Potential to work weekends only. Opportunities for Saturday and Sunday availability. Position Purpose: Collaborate with the Chief Medical Director to oversee medical management, quality improvement, and credentialing functions for the business unit. Responsibilities: Provide medical leadership in utilization management, cost containment, and quality improvement initiatives. Conduct medical review activities for utilization review, quality assurance, and complex cases, ensuring timely decision-making. Support the implementation of performance improvement initiatives for capitated providers. Assist in planning and setting goals to enhance the quality and cost-effectiveness of care for members. Supply medical expertise for utilization management and quality improvement programs in line with regulatory and accreditation standards. Help manage physician committees, including their structure, processes, and membership. Perform regular visits to assess and coordinate care for high-risk patients, collaborating with care management teams. Engage effectively with clinical teams, network providers, appeals teams, and consultants to review complex cases and necessity appeals. Participate in provider network development and market expansion as appropriate. Assist in developing and implementing physician education regarding clinical issues and policies. Evaluate utilization review studies to identify adverse trends and improve service quality. Identify quality improvement studies to mitigate unwarranted clinical practice variations, enhancing care quality and costs. Facilitate the implementation of recommendations aimed at improving utilization and healthcare quality. Review claims involving complex and controversial services to determine medical necessity and correctness of payment. Build relationships within the provider community through the implementation of medical management programs. May represent the business unit at various local and national forums on medical policies and issues as necessary. Join state committees and other ad hoc committees as needed. May work weekends and holidays to support business operations as required. Business Groups and Key Projects: Corporate Responsible for reviewing 12-15 UM decisions daily (inpatient, outpatient, Prior Authorization, etc.) Assess medical necessity against established guidelines. Conduct reviews through the EMR system (Client's system). Perform medical review activities for complex and experimental medical services to ensure quality and timely decisions. Helpful Backgrounds: UM experience (minimum of 1 year). Requirements: Medical Doctor or Doctor of Osteopathy required. Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association. Must Haves: For Behavioral Health only - Board certification by the American Board of Psychiatry and Neurology with an unrestrictive current state medical license. UM experience (minimum of 1 year). Able to obtain licensure in multiple states. Nice to Haves: UM experience. Not meeting the board certification. Performance Indicators: Production capacity around 12-15 cases daily. Quality of the review. A strong candidate would possess the following: Clinical Expertise:
Board-certified physician with active practice experience. UM Proficiency:
Proven ability to manage high-volume case reviews efficiently and accurately. Behavioral Health Experience:
Essential for psychiatry certification roles. Tech Savvy:
Comfortable with EMR systems and virtual collaboration. Adaptability:
Able to work independently in a remote setup while engaging with a dynamic team. Regulatory Knowledge:
Familiar with accreditation standards and state-specific requirements. Referrals can increase your chances of interviewing with Pacer Group.