Medical Director

This is a fully remote position, open to applicants in Illinois, +8 more states.

📋 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 activities related to utilization management, cost reduction, and improvements in medical quality.

• Conduct medical review tasks for utilization reviews, quality assurance, and complex, controversial, or experimental medical services.

• Aid in performance improvement initiatives for capitated providers.

• Assist in the planning and establishment of goals and policies aimed at enhancing the quality and cost-effectiveness of care and services.

• Deliver medical expertise for quality improvement and utilization management programs in compliance with regulatory, state, corporate, and accreditation guidelines.

• Support the structure, processes, and membership of physician committees.

• Perform regular rounds to evaluate and coordinate care for high-risk patients.

• Work collaboratively with clinical teams, network providers, appeals teams, and medical and pharmacy consultants on complex cases and medical necessity appeals.

• Engage in provider network development and new market expansion.

• Assist in educating physicians about clinical matters and policies.

• Identify utilization review studies and assess adverse utilization trends, unusual provider practice patterns, and benefit/payment adequacy.

• Identify clinical quality improvement studies to minimize unwarranted variation and enhance the quality and cost of care.

• Collaborate with physicians and providers to implement suggestions that improve utilization and healthcare quality.

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

• Foster provider-community alliances through medical management initiatives.

• Represent the business unit in front of local and national audiences, state committees, and ad hoc committees as required.

⛳️ Requirements

• MD or DO with no restrictions.

• Must hold a license in one of the following states: Missouri, Illinois, Kansas, Iowa, Nebraska, Michigan, Wisconsin, Indiana, Ohio, or Pennsylvania.

• Medical Doctor or Doctor of Osteopathy.

• Actively practicing medicine.

• 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.

• Certification in Psychiatry specialty is mandatory.

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

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

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

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

• Availability to work weekends and holidays as required.

🏝️ Benefits

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off along with holidays.

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

• Additional forms of incentives may be included in total compensation.