Medical Director

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee a team of clinicians engaged in utilization management activities and strategic clinical initiatives

• Conduct benefit-focused medical necessity evaluations for coverage, case management, and claims resolution

• Utilize benefit plan details, federal and state laws, clinical protocols, and best-practice guidelines

• Strive for quality outcomes for clients with an emphasis on service and cost-effectiveness

• Enhance clinical outcomes through daily collaboration with healthcare professionals, employing education, communication, and negotiation

• Balance the needs of customers/members with business objectives while advocating for clients

• Engage in all levels of the appeal process as necessary

• Contribute to the development of coverage guidelines, medical management initiatives, quality committees, quality assessments, inter-rater reliability evaluations, and quality improvement projects

• Mentor or coach Medical Directors and peers in quality assurance and performance enhancement

• Foster improved relations with healthcare professionals by providing direct communication and evidence-based clinical insights

• Address customer service challenges with support from leadership

• Investigate and respond to inquiries from clients and regulatory bodies

• Ensure prompt coverage review response, quality outcomes, customer satisfaction, and compliance with regulatory/accreditation standards

• Offer clinical insights and management assistance to various functional areas and matrix partners

• Oversee medical management functions for market, regional, or national programs, including utilization review, quality assurance, case management, medical policy formulation, and assessment of new technologies and treatments

• Serve as a senior clinician for market, regional, or national initiatives

• Develop and execute medical management strategic plans

• Support network operations and act as a physician liaison within the community

⛳️ Requirements

• Active unrestricted medical license in a US state or territory

• Current board certification in an ABMS or AOA recognized specialty (either grandfathered by the board or maintained through the MOC program)

• Commitment to ethical and professional conduct

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

• Proficient in word processing, spreadsheet, email, and personal information management software

• Ability to investigate clinical issues using online resources

• Willingness to travel to attend meetings in person as required

• At least three years of experience in medical management, utilization review, and case management within a managed care environment (preferred)

• Familiarity with Pharmacy Claims and utilization management (a plus)

• Understanding of Specialty Pharmaceuticals and their management (a plus)

• Previous experience in managing physicians, nurses, or staff (preferred, but not mandatory)

• Knowledge of managed care products and strategies

• Capability to adapt to a changing business environment while balancing patient advocacy and business priorities

• Experience managing multiple projects in a dynamic matrix setting

• Ability to educate peers and staff members

• Background in change management

• Skills in teamwork, negotiation, conflict resolution, decision-making, and problem-solving

• Ability to analyze complex issues, develop and implement solutions, and address problems

• Capacity to build and maintain cooperative relationships with diverse internal and external stakeholders

• Awareness of culturally diverse situations, participants, and customers/members

• Experience in service marketing, sales, and business acumen (a plus)

• Reliable home internet connection via cable broadband or fiber optic service with a minimum of 10 Mbps download and 5 Mbps upload speed if working remotely

🏝️ Benefits

• Eligibility for annual bonuses

• Long-term incentive plan participation

• Medical insurance coverage

• Vision care benefits

• Dental insurance options

• Well-being and behavioral health programs

• 401(k) retirement plan

• Company-funded life insurance

• Tuition reimbursement opportunities

• A minimum of 18 days of paid time off annually

• Paid holidays

• Leave of absence options

• Remote work opportunities (either occasionally or permanently, subject to internet requirements)