Medical Director

📋 Description

• Conducts medical review and case management tasks.

• Offers clinical insights to the organization through peer reviews, benefit evaluations, consultations, and services provided to both internal and external customers.

• Acts as a clinical educator and consultant for utilization management, case management, network contracting, pharmacy, and service operations (claims).

• Executes benefit-focused medical necessity reviews for coverage, case management, and claims resolution, utilizing benefit plan information, relevant federal and state regulations, clinical guidelines, and best practice principles.

• Strives to achieve quality outcomes for customers/members with an emphasis on service and cost efficiency.

• Enhances clinical outcomes through daily interactions with healthcare professionals by employing active listening, education, and exceptional communication and negotiation skills.

• Balances the needs of customers/members with business objectives while consistently advocating for them.

• Engages in all levels of the Appeal process as permitted by relevant regulatory agencies and accreditation organizations.

• Contributes to the development of coverage guidelines and the maintenance of medical management projects, initiatives, and committees.

• Involves in quality processes such as audits, inter-rater reliability clinical reviews, and quality improvement projects.

• Mentors or coaches other Medical Directors and colleagues in quality and performance enhancement processes.

• Strengthens relationships with healthcare professionals through direct communication, a solid understanding of pertinent evidence-based clinical information, and fostering positive collegial relationships.

• Demonstrates expertise as a peer reviewer by applying current evidence-based guidelines, including innovative treatments, to support high-quality clinical decision-making across various medical and behavioral health conditions, diseases, treatments, and procedures.

• Addresses customer service concerns with guidance and support from leadership staff.

• Investigates and responds to inquiries from clients and/or regulatory agencies to help resolve issues or clarify questions with assistance from leadership staff.

• Achieves internal customer satisfaction and compliance with regulatory/accreditation agency goals by ensuring timely completion of coverage reviews and quality outcomes based on those reviews.

• Provides clinical insights and management support to other functional areas and matrix partners as required or directed.

⛳️ Requirements

• Current unrestricted medical license in a U.S. state or territory.

• Current board certification (lifetime certification or certification maintained through MOC or other applicable programs) in an ABMS or AOA recognized specialty.

• Demonstrates ethical and professional behavior.

• Minimum of 5 years of clinical practice experience and/or direct patient care beyond residency.

• Computer Competency: Proficient in word processing, spreadsheets, email, PowerPoint, and personal information management programs, with the ability to rapidly acquire competency if necessary.

• Must not be excluded from participation in any federal healthcare program.

• Must not be listed on CMS’ Preclusion List.

• Experience in medical management, utilization review, and case management within a managed care environment.

• Knowledge of managed care products and strategies.

• Capable of working within a dynamic business environment while balancing patient advocacy with business requirements.

• Experience managing multiple projects in a fast-paced matrix environment.

• Proven ability to educate colleagues and staff members.

• Successful experience and comfort with change management.

• Demonstrated strong skills in teamwork, negotiation, conflict management, decision-making, and problem-solving.

• Proven success in assessing complex issues, determining and implementing solutions, and resolving problems.

• Ability to create and maintain cooperative, successful relationships with diverse internal and external stakeholders.

• Demonstrated sensitivity to culturally diverse situations, participants, and customers/members.

• Experience in service marketing, sales, and business acumen is a plus.

• Fluency in Spanish or other languages is an advantage.

🏝️ Benefits

• Internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.