Medical Director

This is a fully remote position, open to applicants in United States.

📋 Description

• Provides clinical oversight and manages utilization for Home Health, Durable Medical Equipment (DME), Home Infusion Therapy, Sleep Medicine, and associated services.

• Conducts reviews of medical necessity using clinical criteria and evidence-based guidelines that align with industry standards to support coverage decisions and ensure quality care outcomes.

• Carries out effective medical necessity evaluations and peer-to-peer consultations in compliance with regulatory and compliance turnaround times for cases that may not fulfill clinical criteria.

• Issues adverse determinations as required.

• Offers guidance to both licensed and non-licensed colleagues on clinical matters and case evaluations related to authorization requests and clinical guidelines.

• Engages in peer-to-peer discussions when medical necessity criteria are unmet.

• Participates in CareCentrix Care Coordination, Utilization Management, Quality Improvement, and clinical education initiatives, as needed.

• Maintains clinical integrity in all decisions and interactions with both internal and external stakeholders.

• Collaborates with Health Plan clinical leadership upon request.

• Meets Service Level Agreement (SLA) metrics and performance guarantees as stipulated by health plan clients.

• Engages and supports various committees and clinical rounds as required or assigned.

⛳️ Requirements

• MD or DO with an active and unrestricted medical license.

• Must possess active ABIM or ABMS specialty board certification(s).

• At least 5 years of experience in a relevant clinical practice area.

• Minimum of 3 years’ experience in supporting utilization management reviews, managed care programs, or care delivery networks.

• Proficient in Home Health, DME, and sleep fields, with current knowledge of best practices.

• General understanding of regulatory and accreditation standards for payers and healthcare providers.

• Expertise in Health Plan or Payer Utilization Management (UM).

• Strong team player with the capacity to collaborate effectively across multidisciplinary teams and stakeholders.

• This role necessitates exceptional written and verbal communication skills.

• Projects a strong professional image, shows interest in quality improvement, and maintains a positive attitude towards all assigned tasks.

• Complies with and participates in the Company's mandatory HIPAA privacy program/practices and Business Ethics and Compliance programs/practices.

🏝️ Benefits

• Paid Flex Time Off (FTO)

• 401K Savings Plan

• Paid Parental Leave

• Medical

• Dental

• Vision

• HSA employer contributions

• Dependent Care FSA employer contribution

• Paid Time Off

• Personal/Sick Time

• Award-winning culture