Medical Director

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

📋 Description

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

• Provide medical leadership for utilization management, cost control, and medical quality improvement initiatives.

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

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

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

• Offer medical expertise in the operation of sanctioned quality improvement and utilization management programs in compliance 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, appeals team, and medical and pharmacy consultants to review complex cases and medical necessity appeals.

• Participate in the development of provider networks and the expansion into new markets as appropriate.

• Aid in the creation and implementation of physician education concerning 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 aimed at reducing unwarranted variations in clinical practice to enhance the quality and cost of care.

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

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

• Build alliances with the provider community through the development and implementation of medical management programs.

• May represent the business unit before various audiences locally and nationally on 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 necessary.

⛳️ Requirements

• MD or DO with no restrictions.

• Must hold a license in South Carolina.

• Residency in South Carolina is required.

• Board Certified Physician.

• Preferred experience in Utilization Management and knowledge of quality accreditation standards.

• Actively practicing medicine or has been an actively practicing physician within the last 5 years.

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

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

• 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 South Carolina 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 approach with options for remote, hybrid, field, or office schedules.