Pediatrics - Physician
Not Disclosed•Full-TimeOn-site
location_onLight Company Road, Houston, Harris County, Texas, 77506, United States
About the Team
Founded in 1996, Texas Children's Health Plan is the nation's first health maintenance organization (HMO) created specifically for children. As the largest combined STAR/CHIP Managed Care Organization in the Harris County service area, we provide STAR/Medicaid and Children's Health Insurance Program (CHIP) coverage to pregnant women, teens, children, and adults in Houston and surrounding areas. Our network supports over 375,000 members through more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals.
About the Role
As an Associate Medical Director for Managed Care and Utilization Management, you will join the best-ranked children's hospital in Texas and among the best in the nation. This role is pivotal in establishing health plans and medical policies that drive high-quality care. You will serve as a crucial member of the Health Plan operating team, providing guidance to various departments within Texas Children's Health Plan (TCHP).
In this position, you will oversee assigned functions of the health plan while offering support, education, and consultation to Texas Children's System staff and physicians regarding resource utilization, managed care, and continuity of care. Working closely with Chief Medical Officers (CMOs) and Medical Directors, you will help continuously improve medical management programs, including discharge planning, case and referral management, and the application of clinical protocols. Your work ensures that the Utilization Management Program reflects current managed care philosophies and the core values of Texas Children's.
You will play a key role in developing standards for behavioral health care, practice guidelines, and medication management. This includes completing medical necessity reviews and appeals based on evidence-based guidelines approved by the CAAC, ensuring decisions are made with independent clinical judgment free from fiscal influence. Additionally, you will monitor member outcomes using encounter and claims data, identify strategies to improve health status, and ensure strict regulatory compliance with agencies such as NCQA and TDI.
Hiring Process
Interested candidates should submit their application through the official career portal. The selection process typically involves a review of qualifications followed by interviews with the CMOs and relevant department heads to assess clinical expertise and cultural fit.
Equal Opportunity
Texas Children's Health Plan is an equal opportunity employer committed to diversity and inclusion. We consider qualified applicants regardless of background, race, color, religion, gender, sexual orientation, age, disability, or veteran status.
Work location
Work model: On-site
Light Company Road, Houston, Harris County, Texas, 77506, United States
Houston, Texas
Key Responsibilities
- check_circleEstablish health plans and medical policies for the organization
- check_circleOversee implementation of medical management programs including discharge planning and case management
- check_circleConduct medical necessity reviews and appeals using evidence-based guidelines
- check_circleDevelop behavioral health care guidelines and practice standards
- check_circleParticipate in Quality Management programs and establish quality improvement standards
- check_circleProvide education and consultation to staff and physicians on resource utilization and managed care
- check_circleMonitor member outcomes using encounter, claims, and electronic medical record data
- check_circleEnsure regulatory compliance with NCQA, TDI, and federal accreditation agencies
Requirements
- verifiedDoctor of Medicine (M.D.) or Doctorate Doctor of Osteopathic Medicine (D.O.)
- verifiedMDL - Medical Doctor License by the Texas Medical Board
- verifiedBCPP - BC Physician in Psychiatry by the American Board of Psychiatry & Neurology OR BCP - Cert-Board Cert Pediatrician by the American Board of Pediatrics OR BCFM - Cert-Board Cert Family Medicine by the American Board of Family Medicine OR BCOBGYN - Cert - Board Certified OB-GYN by the American Board of Medical Obstetrics and Gynecology
- verified5 years Healthcare management, managed care experience, and/or behavioral health experience
- verifiedResidency in Psychiatry and Child Psychiatry training, when primary role of the Associate Medical Director is Behavioral Health
Nice to Have
Board certification in Pediatrics and Family Medicine
Similar Job Opportunities
Skills, education and keywords
Skills: Managed Care, Utilization Management, Medical Policies, Discharge Planning, Case Management, Referral Management, Clinical Protocols, Medical Review Criteria, Behavioral Health Care, Practice Guidelines.
Education: Required Doctor of Medicine (M.D.) or Doctorate Doctor of Osteopathic Medicine (D.O.).
Frequently asked questions about Pediatrics - Physician at Texas Children's Hospital
What does a Pediatrics - Physician at Texas Children's Hospital do?expand_more
A Pediatrics - Physician at Texas Children's Hospital is responsible for the following: Establish health plans and medical policies for the organization; Oversee implementation of medical management programs including discharge planning and case management; Conduct medical necessity reviews and appeals using evidence-based guidelines; and Develop behavioral health care guidelines and practice standards.
What are the requirements for this Pediatrics - Physician role?expand_more
To qualify for the Pediatrics - Physician at Texas Children's Hospital position, applicants should have: Doctor of Medicine (M.D.) or Doctorate Doctor of Osteopathic Medicine (D.O.); MDL - Medical Doctor License by the Texas Medical Board; BCPP - BC Physician in Psychiatry by the American Board of Psychiatry & Neurology OR BCP - Cert-Board Cert Pediatrician by the American Board of Pediatrics OR BCFM - Cert-Board Cert Family Medicine by the American Board of Family Medicine OR BCOBGYN - Cert - Board Certified OB-GYN by the American Board of Medical Obstetrics and Gynecology; 5 years Healthcare management, managed care experience, and/or behavioral health experience; and Residency in Psychiatry and Child Psychiatry training, when primary role of the Associate Medical Director is Behavioral Health.
Where is the Pediatrics - Physician role at Texas Children's Hospital located?expand_more
Pediatrics - Physician at Texas Children's Hospital is based in Light Company Road, Houston, Harris County, Texas, 77506, United States. This is a on-site role.
Is this Pediatrics - Physician job remote, hybrid, or on-site?expand_more
Texas Children's Hospital has listed this Pediatrics - Physician role as on-site.
How much experience is required for this Pediatrics - Physician role?expand_more
Pediatrics - Physician at Texas Children's Hospital typically requires 5+ years of relevant experience at the senior level.
What skills do you need for the Pediatrics - Physician role at Texas Children's Hospital?expand_more
Key skills for Pediatrics - Physician at Texas Children's Hospital include Managed Care; Utilization Management; Medical Policies; Discharge Planning; Case Management; Referral Management; Clinical Protocols; and Medical Review Criteria.
What education is required for Pediatrics - Physician at Texas Children's Hospital?expand_more
Educational requirements for this role: Required Doctor of Medicine (M.D.) or Doctorate Doctor of Osteopathic Medicine (D.O.).
What category does the Pediatrics - Physician role belong to?expand_more
Pediatrics - Physician at Texas Children's Hospital is part of the healthcare & nursing job category on Recrutus.