Medical Director

This is a fully remote position, open to applicants in Alabama, +17 more states.

📋 Description

• Conducts benefit-oriented medical necessity evaluations for coverage, case management, and claims resolution, utilizing benefit plan details, relevant federal and state regulations, clinical guidelines, and best practice standards.

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

• Enhances clinical outcomes through daily engagement with healthcare professionals, employing active listening, educational efforts, and exemplary communication and negotiation skills.

• Balances the needs of customers/members with business objectives while consistently acting as an advocate for them.

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

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

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

• Acts as a mentor or coach to other Medical Directors and colleagues in quality and performance enhancement processes.

• Strengthens relationships with healthcare professionals through direct communication, knowledge of relevant evidence-based clinical information, and the cultivation of 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 medical and behavioral health conditions, diseases, treatments, and procedures.

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

• Investigates and responds to client and/or regulatory inquiries to assist in issue resolution or clarification, with mentoring and support from leadership staff.

• Achieves internal customer satisfaction and complies with regulatory/accreditation agency standards by ensuring timely turnaround of coverage reviews and quality outcomes based on those review decisions.

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

⛳️ Requirements

• Possession of a current unrestricted medical license in a US state or territory.

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

• Demonstrates ethical and professional conduct.

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

• Computer proficiency: Extensive use of word processing, spreadsheet, email, PowerPoint, and personal information management programs; competency in all is required or must be quickly acquired.

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

• Must not be listed on CMS' Preclusion List.

🏝️ Benefits

• Medical, vision, dental, and well-being and behavioral health programs.

• 401(k).

• Company-paid life insurance.

• Tuition reimbursement.

• A minimum of 18 days of paid time off per year.

• Paid holidays.

• Leaves of absence.