Medical Director

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

📋 Description

• Conduct benefit-oriented medical necessity assessments for coverage, case management, and resolution of claims.

• Utilize benefit plan details, federal and state regulations, clinical protocols, and best-practice methodologies.

• Strive for quality outcomes for customers and members, emphasizing service and cost-effectiveness.

• Enhance clinical results through daily engagement with healthcare professionals, utilizing listening, education, communication, and negotiation skills.

• Balance the needs of customers/members with business objectives while advocating on their behalf.

• Engage in all relevant stages of the appeals process.

• Contribute to the development of coverage guidelines and participate in medical management initiatives and committees.

• Take part in audits, inter-rater reliability clinical assessments, and quality improvement projects.

• Mentor or coach Medical Directors and peers on quality and performance enhancements.

• Strengthen relationships with healthcare professionals through direct communication and evidence-based clinical information.

• Implement evidence-based guidelines, including innovative treatments, across a range of medical and behavioral health conditions, diseases, treatments, and procedures.

• Continuously update clinical knowledge via monthly coverage-policy updates, inter-rater reliability testing, ongoing medical education, and maintenance of board certification.

• Address customer service concerns with support from leadership.

• Investigate and respond to inquiries from clients and regulatory bodies.

• Ensure timely coverage-review processes and quality outcomes to meet customer satisfaction and regulatory/accreditation requirements.

• Offer clinical insights and management support to various functional areas and matrix partners as necessary.

⛳️ Requirements

• A valid, unrestricted medical license in a US state or territory.

• Current board certification in a specialty recognized by ABMS or AOA, maintained through lifetime certification, MOC, or another relevant program.

• Demonstrated ethical and professional conduct.

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

• Proficiency in word processing, spreadsheets, email, PowerPoint, and personal information management software.

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

• Must not be listed on CMS’ Preclusion List.

• Preferred experience in medical management, utilization review, and case management in a managed care environment.

• Knowledge of managed care products and strategies is preferred.

• Ability to balance patient advocacy with business interests is preferred.

• Experience managing multiple projects in a dynamic matrix environment is preferred.

• Capability to educate colleagues and staff members is preferred.

• Experience with change management is preferred.

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

• Ability to evaluate complex issues, implement solutions, and resolve challenges is preferred.

• Capacity to build and maintain collaborative relationships with diverse internal and external stakeholders is preferred.

• Awareness and sensitivity to culturally diverse situations, participants, and customers/members is preferred.

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

🏝️ Benefits

• Eligibility for an annual bonus.

• Participation in a long-term incentive plan.

• Comprehensive medical insurance.

• Vision insurance coverage.

• Dental insurance offerings.

• Access to 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 each year.

• Paid holidays.

• Leaves of absence policies.

• Requirement for cable broadband or fiber optic internet for remote work, with a minimum speed of 10Mbps download and 5Mbps upload.