Medical Director

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

📋 Description

• Offer subject matter expertise and medical leadership for utilization management, care management, and quality-of-care programs specifically for infant and neonatology services.

• Collaborate with Vice Presidents of Utilization Management, Care Management, and Medical Directors to meet utilization, care management, and quality-of-care goals for newborn and infant members and their mothers.

• Deliver staff training, clinical consultation, and conduct clinical case reviews.

• Execute prior authorization medical reviews, consultations, and clinical review services.

• Engage in peer-to-peer discussions.

• Provide education and training to providers, share data, conduct performance evaluations, and offer orientation to the plan.

• Conduct physician reviews for clinical appeal cases.

• Assess and investigate suspected fraud, abuse, and quality-of-care issues.

• Take part in quality improvement, case management, and member safety initiatives.

• Oversee and enhance case management activities.

• Analyze utilization data, identify pattern variances, and offer feedback and education to plan staff and providers.

• Develop, implement, and refine clinical care standards and practice guidelines in line with nationally accepted quality standards.

• Formulate, execute, and update the Quality Improvement Plan and corporate quality initiatives.

• Work with market and product leaders to establish market strategies.

• Act as a liaison with community-based organizations and health systems regarding neonatal prevention, care coordination, and care management.

• Assist in regulatory, accreditation, and compliance functions, including CMS, state requirements, NCQA, and URAC.

• Participate in Utilization Management rounds and educate UM staff on NICU utilization management, levels of care, and quality of care.

• Develop and enhance transitions of care for NICU members graduating from the NICU.

• Create formal clinical policies for NICU and post-NICU transitions and care management.

• Perform additional duties as requested.

⛳️ Requirements

• Must have completed an accredited Medical Degree program as an MD or DO.

• Successful completion of a pediatrics residency and neonatology fellowship, or equivalent experience, is essential.

• A minimum of five (5) years of clinical practice experience is required.

• Must possess a current, unrestricted license to practice medicine in the state of practice, as mandated by regulatory requirements.

• Board certification in Pediatrics is necessary, preferably in a primary care specialty.

• Board certification in Neonatology is required.

• Specialty board re-certification must be kept up-to-date.

• Basic proficiency in Microsoft Word is required.

• Exceptional written and oral communication skills are essential.

• Ability to work independently as well as collaboratively within a team environment.

• Capability to build strong relationships with providers and members.

• High ethical standards must be maintained.

• Strong attention to detail is required.

• Critical listening and systematic thinking abilities are necessary.

• Ability to maintain confidentiality and act in the company's best interests.

• Must demonstrate diplomacy and sensitivity to cultural diversity.

• Strong decision-making and problem-solving skills are essential.

• Proficient conflict resolution skills are necessary.

• A strong sense of mission and commitment to the communities served is required.

• Willingness to work evenings and weekends as needed.

• Must be willing to travel as required.

🏝️ Benefits

• Bonus linked to company and individual performance.

• Comprehensive total rewards package.

• Employee total well-being support.

• Equal opportunity and belonging-focused workplace.