Inpatient Medicare Medical Director

This is a fully remote position, open to applicants in Florida, +2 more states.

📋 Description

• Assist the Chief Medical Director in overseeing and coordinating medical management, quality improvement, and credentialing functions.

• Provide medical leadership for utilization management, cost containment, and activities aimed at enhancing medical quality.

• Conduct utilization reviews, quality assurance evaluations, and medical assessments of complex, controversial, or experimental medical services.

• Support performance improvement initiatives for capitated providers.

• Help set goals and policies to enhance the quality and cost-effectiveness of member care and services.

• Offer medical expertise for quality improvement and utilization management programs in alignment with regulatory, state, corporate, and accreditation standards.

• Assist with the structure, processes, and membership of physician committees.

• Conduct regular rounds to evaluate and coordinate care for high-risk patients alongside care management teams.

• Collaborate with clinical teams, network providers, appeals teams, and medical and pharmacy consultants on intricate cases and medical necessity appeals.

• Participate in the development of the provider network and the expansion into new markets.

• Assist in educating physicians about clinical issues and policies.

• Identify utilization review studies and assess adverse utilization trends, unusual provider practice patterns, and the adequacy of benefits/payments.

• Identify clinical quality improvement studies to minimize unwarranted variations in clinical practice.

• Engage with physicians and providers to implement recommendations that enhance utilization and healthcare quality.

• Review complex, controversial, unusual, or new-service claims to evaluate medical necessity and appropriate payment.

• Develop alliances within the provider community through medical management programs.

• Represent the business unit on medical philosophy, policies, related issues, state committees, and ad hoc committees as required.

• Work on weekends and holidays as necessary to support business operations.

⛳️ Requirements

• Medical Doctor (MD) or Doctor of Osteopathy (DO).

• Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services.

• Current unrestricted state license as an MD or DO, without any restrictions, limitations, or sanctions from government programs.

• Actively practicing medicine.

• Experience in Utilization Management and familiarity with quality accreditation standards is preferred.

• Active American Board Certification in Internal or Family Medicine is preferred.

• Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.

• Experience in treating or managing care for a culturally diverse population is preferred.

• Availability to work weekends and holidays as necessary.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K plans.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work options including remote, hybrid, field, or office work schedules.

• Additional forms of incentives may be incorporated into total compensation.