Medical Director, Inpatient Medicare

This is a fully remote position, open to applicants in Florida, +2 more states.

📋 Description

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

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

• Conduct medical review tasks related to utilization review, quality assurance, and complex, controversial, or experimental medical services.

• Aid in the development of performance improvement initiatives for capitated providers.

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

• Provide medical guidance for quality improvement and utilization management programs, ensuring compliance with regulatory, state, corporate, and accreditation standards.

• Support the structure, processes, and membership of physician committees.

• Perform regular rounds for high-risk patients and work alongside care management teams.

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

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

• Assist with educating physicians on clinical matters and policies.

• Identify utilization review studies and assess adverse utilization trends, atypical provider practice patterns, and the adequacy of benefits/payments.

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

• Work 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.

• Build alliances with the provider community through medical management initiatives.

• Represent the business unit in local and national forums regarding medical philosophy, policies, and related topics as necessary.

• Represent the business unit at state and ad hoc committees.

⛳️ Requirements

• Medical Doctor or Doctor of Osteopathy degree.

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

• Current unrestricted state license as a MD or DO, free from government program sanctions or limitations.

• Actively engaged in the practice of medicine.

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

• Active Certification in Internal or Family Medicine preferred.

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

• Experience in treating or managing care for a culturally diverse population is preferred.

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

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase plans available.

• Tuition reimbursement offered.

• Paid time off along with holidays.

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

• Additional incentives may be included in the overall compensation package.