Medical Director

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Lead, guide, and provide daily assistance for the designated region of New Jersey and the assigned healthcare providers.

• Facilitate utilization management, care management, disease management, quality management, pharmacy management, post-service reviews, provider education, provider relations issues, and clinical transformation.

• Manage a personal caseload of daily medical management tasks and enhance the operational efficiency of the medical management program.

• Support all lines of business, including both Commercial and Government Programs.

• Collaborate with value-based teams, Behavioral Health, Pharmacy, accounts, and cross-functional regional teams; assist sales teams as required.

• Mentor, support, and provide guidance to nurse reviewers regarding pre-authorization, concurrent and retrospective reviews, post-service reviews, pre-determinations, and decision-making.

• Consult with and aid case management in determining the optimal course for members, assist with PG, and address any arising issues.

• Establish and sustain collaborative relationships with providers through on-site or virtual performance reviews and coaching activities.

• Contribute to provider credentialing, profiling, and communication initiatives.

• Analyze case management and utilization data, pinpoint issues, and escalate concerns to senior management as necessary.

• Interpret utilization, cost, and quality reports while developing strategies to address performance discrepancies.

• Collaborate on monthly reporting documentation for the designated region.

• Evaluate network capabilities by region and work together on network gaps with network management, contracting, and value-based teams.

• Create or engage in internal and external educational initiatives.

• Participate in assigned committee activities and serve as a backup chair for committees.

• Provide support across functional Medical Director teams and engage in calls for all areas.

• Assist in the development of medical policy, review medical and pharmacy policies, and offer utilization feedback.

• Collaborate with legal and mandate teams to ensure compliance with the New Jersey Department of Banking and Insurance.

• Conduct medical reviews for the Clinical Inquiries Team and support the special investigations unit as needed.

• Aid in the development and implementation of reimbursement policies.

⛳️ Requirements

• Strong knowledge of Utilization Management, Case Management, Quality Management, and accreditation/regulatory standards.

• Extensive clinical knowledge and awareness of current healthcare issues and trends.

• Understanding of health insurance payer operations and business practices.

• Board Certification in a specialty recognized by the American Board of Medicine.

• Current unrestricted MD or DO license to practice medicine.

• 5-7 years of clinical experience.

• Experience in data management to identify key issues, develop recommendations, and present findings to executive management.

• Proficiency in using Tableau or similar data visualization software.

• Competence in a Windows-based environment, including proficiency with MS Office products.

• Ability to review studies, comprehend evidence-based medicine, and assist in medical policy development.

• Capability to chair committees with internal and external stakeholders.

• Active Unrestricted MD or DO License required; NJ License necessary.

• No history of CMS Sanctions or sanctions by other regulatory agencies or boards.

• Must be board certified by a specialty recognized by the American Osteopathic Association or the American Board of Medical Specialties.

• Ability to work effectively in a matrix environment, including leading and collaborating with cross-functional teams.

• Skill in identifying conflicts, understanding their causes, and negotiating mutually acceptable solutions.

• Access to a vehicle and the ability to travel for meetings with physicians, hospitals, and ancillary providers as needed.

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement