Consultant Medical Director, Utilization Review

  • Avalon Healthcare Solutions
  • Charlotte, North Carolina
  • Jan 12, 2019
Information Technology

Job Description

ID 2018-1114
# of Openings 1
Category Medical Policy


About the Company:

Avalon Healthcare Solutions, headquartered in Tampa, Florida, is a clinical services and information technology company using evidence-based medicine to develop and deploy medical policies and protocols in the high-volume, dynamic and complex diagnostic lab environment. The company manages the appropriate use of thousands of existing lab tests and researches new tests to determine efficacy and impact on patient care.

Studies show that 30% of clinical laboratory testing is unnecessary or overused. Inappropriate testing or missing a key screening can lead to complications and expense arising from unwarranted care, or not obtaining proper care when needed, leading to increased health risks and costs. Avalon helps ensure delivery of the right test, at the right time, and in the right setting. We seek to ensure the most effective patient treatment, improve clinical outcomes, and optimize cost and affordability.

Avalon is a portfolio company of Francisco Partners, a global private equity firm that specializes in investments in technology and technology-enabled service companies. Since its launch 15 years ago, FP has raised approximately $10 billion and invested in more than 150 companies.

Avalon is a high growth company where every associate has an opportunity to make a difference. You will be part of a team that shapes a new market and business. You'll enjoy seeing the results of your work as we rapidly implement our plan. Most importantly, you will help Avalon to achieve its mission and improve clinical outcomes and health care affordability for the people we serve.

For more about Avalon, please visit our web site at

About the Consultant Medical Director, Utilization Review :

The Medical Director, Utilization Review provides clinical support to the prior authorization team and Medical Director, Vice President to ensure that utilization management activities are performed in accordance with the highest and most current clinical standards. Responsible to review cases and evaluate the medical necessity and appropriateness of the requested laboratory service. The Medical Director, Utilization Review is responsible for compliance with NCQA, URAC, CMS, DOH, and DOL regulations. This role is responsible for appropriate application of Medical Policy and criteria sets.


Consultant Medical Director, Utilization Review - Essential functions and responsibilities:
  • Serves as a resource for information and consultation on the issues related to utilization management and clinical services
  • Conducts medical necessity reviews based on individual member plan documents, Avalon's Medical Policy and national/proprietary coverage review guidelines
  • Renders coverage determinations and discuss with requesting providers as needed in peer-to-peer telephone calls
  • Composes clear and concise clinical rationales for members and provider determination notifications
  • Other assigned duties as assigned


Consultant Medical Director, Utilization Review - Qualifications:

  • Holds a North Carolina Medical License
  • Five (5) years experience in healthcare delivery and utilization review services
  • MD or DO with a current, unrestricted medical license
  • Board certified in an American Board of Medical Specialties or Bureau of Osteopathic Specialists recognized specialty
  • Excellent communication skills including good grammar, voice and diction.
  • Ability to navigate and master proprietary software programs and proficient in MS Office with basic computer and keyboarding skills.

Consultant Medical Director, Utilization Review - Preferred Qualifications:
  • It is desirable that the candidate maintains some level of active clinical practice.
  • It is preferable that the applicant has some prior knowledge of CPT codes related to molecular pathology procedures (both specific and non-specific).
  • Knowledge of URAC, NCQA, DOL, DOH and CMS standards and operating procedures