Medical Director, Inpatient Medicare

This is a fully remote position, open to applicants in Arizona, +4 more states.

📋 Description

• Support the Chief Medical Director in overseeing and coordinating medical management, quality enhancement, and credentialing functions.

• Offer medical leadership for utilization management, cost control, and initiatives aimed at improving medical quality.

• Conduct utilization reviews, quality assurance assessments, and medical evaluations for complex, controversial, or experimental medical services.

• Aid in performance improvement projects for capitated providers.

• Assist in setting objectives and policies that enhance the quality and cost-effectiveness of care and services.

• Provide medical expertise for programs focused on quality improvement and utilization management.

• Support physician committees regarding their structure, processes, and membership.

• Perform regular rounds for high-risk patients and coordinate care with care management teams.

• Collaborate with clinical teams, network providers, appeals teams, and medical and pharmacy consultants on complex cases and medical necessity appeals.

• Engage in provider network development and expansion into new markets.

• Assist in physician education concerning clinical matters and policies.

• Identify studies for utilization review, adverse utilization trends, unusual provider practice patterns, and issues related to benefit/payment adequacy.

• Pinpoint clinical quality improvement studies aimed at reducing unwarranted variation and enhancing the quality and cost of care.

• Interface with physicians and providers to implement recommendations that enhance utilization and healthcare quality.

• Review complex, controversial, unusual, or new-service claims to assess medical necessity and appropriate payment.

• Foster provider-community alliances through medical management programs.

• Represent the business unit on medical philosophy, policies, related issues, state committees, and ad hoc committees as required.

• Availability to work weekends and holidays to support business operations as needed.

⛳️ Requirements

• Medical Doctor (MD) or Doctor of Osteopathy (DO) degree.

• Current unrestricted state license as an MD or DO, with no restrictions, limitations, or sanctions from government programs.

• Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services.

• Actively engaged in practicing medicine.

• Preferred experience in Utilization Management and knowledge of quality accreditation standards.

• Preferred active American Board Certification in Internal or Family Medicine.

• Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.

• Preferred experience in treating or managing care for a culturally diverse population.

• Willingness to work weekends and holidays as required.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plans.

• Stock purchase plans.

• Tuition reimbursement program.

• Paid time off plus holidays.

• Flexible work options including remote, hybrid, field, or office work schedules.

• Additional incentive forms may be included in the total compensation package.