Medical Director

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

📋 Description

• Oversee a team of clinicians to achieve excellent organizational results through utilization management tasks and strategic clinical initiatives.

• Conduct benefit-focused medical necessity evaluations for coverage, case management, and claims resolution utilizing benefit plan details, federal and state regulations, clinical guidelines, and best-practice principles.

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

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

• Reconcile customer/member needs with business objectives while acting as a customer advocate.

• Engage in all stages of the appeal process as necessary.

• Contribute to the development of coverage guidelines, medical management project creation and maintenance, and participation in quality committees.

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

• Provide mentorship or coaching to Medical Directors and colleagues regarding quality and performance enhancement processes.

• Foster improved relations with healthcare professionals through direct communication and evidence-based clinical insights.

• Address customer service challenges with guidance and support from leadership.

• Investigate and address inquiries from clients and regulatory bodies.

• Attain customer satisfaction and ensure compliance with regulatory/accreditation standards through timely coverage assessments and quality results.

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

• Direct medical management activities for market, regional, or national programs, including utilization review, quality assurance, case management, medical policy formulation, and evaluation of new technologies and treatments.

• Serve as a senior clinician for market, regional, or national programs as required.

• Develop and execute strategic plans for medical management.

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

⛳️ Requirements

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

• Active board certification in an ABMS or AOA recognized specialty (either grandfathered by the board or maintained via the MOC program).

• Display ethical and professional conduct.

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

• Proficiency in computer applications such as word processing, spreadsheets, email, and Personal Information Management software.

• Capability to research clinical topics using online resources.

• Willingness to travel for in-person meetings as necessary.

• Minimum of three years’ 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).

• Prior experience in managing physicians, nurses, or employees (a plus but not mandatory).

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

• Knowledge of managed care products and strategies.

• Ability to adapt to a dynamic business environment while balancing patient advocacy with organizational needs.

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

• Proven ability to educate colleagues and staff members effectively.

• Successful track record and comfort with change management.

• Strong skills in teamwork, negotiation, conflict resolution, decision-making, and problem-solving.

• Capacity to evaluate complex issues, determine and implement solutions, and resolve challenges.

• Ability to cultivate and maintain cooperative relationships with a diverse range of internal and external stakeholders.

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

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

• For remote or occasional work-from-home arrangements, a cable broadband or fiber optic internet service with a minimum of 10 Mbps download and 5 Mbps upload speed is required.

🏝️ Benefits

• Eligibility for annual bonuses.

• Participation in a long-term incentive plan.

• Comprehensive medical benefits.

• Vision insurance coverage.

• Dental insurance offerings.

• Access to well-being and behavioral health programs.

• 401(k) retirement plan.

• Company-paid life insurance.

• Tuition reimbursement opportunities.

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

• Paid holidays.

• Leaves of absence available.

• Implementation of a tobacco-free policy.