Medical Director

This is a fully remote position, open to applicants in Missouri, +1 more state.

📋 Description

• Assist the Chief Medical Director in directing and coordinating the medical management, quality improvement, and credentialing functions for the business unit.

• Provide medical leadership across utilization management, cost containment, and medical quality improvement initiatives.

• Conduct medical review activities related to utilization review, quality assurance, and the assessment of complex, controversial, or experimental medical services, ensuring timely and quality decision-making.

• Support the effective implementation of performance improvement initiatives for capitated providers.

• Aid the Chief Medical Director in planning and establishing goals and policies aimed at enhancing the quality and cost-effectiveness of care and services for members.

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

• Assist the Chief Medical Director in the operation of physician committees, including committee 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, the appeals team, and medical and pharmacy consultants to review complex cases and medical necessity appeals.

• Participate in provider network development and new market expansion as appropriate.

• Assist in the creation and implementation of physician education regarding clinical issues and policies.

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

• Identify clinical quality improvement studies to help reduce unwarranted variation in clinical practice to improve the quality and cost of care.

• Interface with physicians and other providers to facilitate the implementation of recommendations aimed at improving utilization and healthcare quality.

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

• Develop alliances with the provider community through the creation and implementation of medical management programs.

• May represent the business unit before various stakeholders both locally and nationally on medical philosophy, policies, and related issues as needed.

• 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 when necessary.

⛳️ Requirements

• Medical Doctor or Doctor of Osteopathy.

• Experience in Utilization Management and knowledge of quality accreditation standards preferred.

• Actively practicing medicine.

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

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

• Certification in Internal or Family Medicine is preferred.

• Current state license as an MD or DO without 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 work schedules.