Medical Director

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

📋 Description

• Support the Chief Medical Director in overseeing and coordinating medical management, quality enhancement, and credentialing operations for the business unit.

• Provide medical leadership for all aspects of utilization management, cost control, and activities focused on improving medical quality.

• Conduct medical review processes related to utilization assessments, quality assurance, and the review of complex, controversial, or experimental medical services, ensuring prompt and high-quality decision-making.

• Aid in the effective execution of performance improvement initiatives for capitated providers.

• Assist the Chief Medical Director in the formulation and establishment of goals and policies aimed at enhancing the quality and cost-effectiveness of care and services for members.

• Offer medical expertise in the management of approved quality improvement and utilization management programs, adhering to regulatory, state, corporate, and accreditation standards.

• Assist the Chief Medical Director in the operations of physician committees, including their structure, processes, and membership.

• Conduct regular rounds to evaluate and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.

• Collaborate effectively with clinical teams, network providers, appeals teams, and medical and pharmacy consultants to review complex cases and medical necessity appeals.

• Engage in provider network development and new market expansion as applicable.

• Assist in the creation and execution of physician education on clinical issues and policies.

• Identify utilization review studies and assess adverse trends in the use of medical services, unusual provider practices, and adequacy of benefits/payment components.

• Identify clinical quality improvement studies aimed at reducing unwarranted variations in clinical practice to enhance the quality and cost of care.

• Interface with physicians and other providers to facilitate the implementation of recommendations that would improve utilization and healthcare quality.

• Review claims involving complex, controversial, or new services to determine medical necessity and appropriate payment.

• Foster alliances with the provider community through the creation and execution of medical management programs.

• As necessary, may represent the business unit before various public audiences both locally and nationally regarding medical philosophy, policies, and related issues.

• Represent the business unit at relevant state committees and other ad hoc committees.

• May be required to work weekends and holidays to support business operations as needed.

⛳️ Requirements

• MD or DO without any restrictions.

• Board Certified Physician.

• Must hold a valid license in Florida.

• Resident of Florida.

• Internal Medicine or Family Medicine is highly preferred.

• Prior experience in Utilization Management and knowledge of quality accreditation standards is preferred.

• Actively practicing medicine or have practiced as a physician within the last five years.

• 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.

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

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K and stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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