Director Medical Management

Miami, FL

Full Time

Experienced

Position Summary:
The Director of Medical Management is responsible for the strategic direction, leadership, and oversight of all medical management functions, including Utilization Management, and Quality Improvement initiatives. This role ensures effective care coordination, promotes quality healthcare delivery, manages healthcare costs, and ensures compliance with regulatory and accreditation requirements. This position is responsible for the day-to-day management of the Medical Management Department staff, based upon established goals and objectives.

Key Responsibilities:

Lead and manage the day-to-day operations of the Medical Management department, ensuring the delivery of high-quality, cost-effective, and patient-centered care.
Oversee Utilization Management to ensure alignment with organizational goals and compliance with regulations.
Develop, implement, and monitor strategies to manage medical expenses and improve clinical outcomes.
Collaborate with internal stakeholders including the Chief Medical Officer, Provider Relations, Claims, and IT to ensure seamless integration of medical management processes.
Ensure all activities meet accreditation standards and federal/state regulatory requirements.
Lead, mentor, and develop a multidisciplinary team of clinical and non-clinical staff.
Use data analytics and reporting to drive decision-making, identify trends, and implement improvement strategies.
Monitor performance metrics (e.g., readmission rates, inpatient days, ER utilization) and lead quality improvement initiatives to enhance health outcomes.
Serve as a liaison with external stakeholders, including providers, vendors, and regulatory agencies.
Develop and manage the medical management budget, ensuring efficient resource allocation.
Directs and oversees the operations and strategic planning of the organization’s medical management initiatives and programs.
Oversees a staff of Hospital Reviewers/Utilization Managers, Medical Management Coordinator RNs, Medical Management Coordinators.
Manages the daily concurrent review process through department staff, including review of daily hospital census reports, discharge planning, and other associated activities.
Manages the daily workflow of incoming pre-certification requests, ensuring they are appropriately allocated.
Manages the administrative denial process to ensure that regulatory requirements are followed.
Assesses and identifies departmental goals, develops and implements action plans, in order to achieve objectives.
Ensures staff compliance with organizational policies and external regulatory agencies and takes leadership responsibility to coordinate the integration of the department's patient care and processes to ensure continuity of care and optimal clinical resource utilization.
Interviews and hires department staff.
Performs other job-related duties as assigned from time to time by the Chief Medical Officer

Qualifications:
Education:

Bachelor’s degree in Nursing, Healthcare Administration, or a related field required.
Master’s degree in Nursing, Public Health, Business, or Healthcare Administration preferred.

Licensure/Certification:

Active RN license required (state-specific or compact).
Additional certifications in healthcare management or quality improvement are a plus.

Experience:

Minimum 5–10 years of progressively responsible experience in medical management, or utilization review within a healthcare plan, ACO, or provider system.
At least 3–5 years in a leadership or director-level role managing teams.
Strong knowledge of regulatory requirements, accreditation standards, and managed care principles.
Medicare Managed care experience preferred

Skills:

Excellent leadership, organizational, and interpersonal skills.
Strong analytical and problem-solving abilities.
Proficient in medical management software and data analytics platforms.
Ability to manage change and drive performance improvement.

Able to work in a collaborative fashion with a variety of departments within the Plan.
Outstanding oral and written communication skills.
Experience with Microsoft software programs including Excel, Access, and PowerPoint.

Work Environment:

Standard office environment.
May require occasional travel to organizational or provider sites.

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

No Third Party Agencies or Submissions Will Be Accepted.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

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Do you hold a Bachelor’s degree in Nursing, Healthcare Administration, or a related field? (Required)*

Do you hold a Master’s degree in Nursing, Public Health, Business, or Healthcare Administration? (Preferred)*

Do you hold an active RN license, (state-specific or compact)? (Required)*

How many years' experience do you have of progressively responsible experience in medical management, or utilization review within a healthcare plan, ACO, or provider system? (Required).*

Do you have at least 3–5 years in a leadership or director-level role managing teams? (Required)*

Do you have Medicate Managed care experience? (Preferred)*

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