Medical Director – Part Time

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

📋 Description

• Offer physician leadership in the creation, execution, and continuous assessment of evidence-based clinical guidelines, medical policies, and utilization management protocols to facilitate high-quality, clinically appropriate decision-making.

• Guarantee that clinical programs, utilization review processes, and medical management procedures align with contemporary standards of care, evidence-based medicine, accreditation standards, and relevant federal and state regulations.

• Act as the clinical authority for intricate, high-risk, or escalated utilization review cases by delivering medical expertise, interpreting benefits, and making final determinations on medical necessity as needed.

• Enhance consistency, precision, and defensibility in medical decision-making by applying sound clinical judgment and established medical necessity criteria across all review activities.

• Collaborate with Clinical Operations, Compliance, Legal, and executive leadership to formulate, assess, and amend clinical and administrative policies, medical necessity guidelines, and benefit interpretation criteria.

• Observe alterations in clinical practice guidelines, healthcare regulations, payer requirements, and industry best practices, suggesting updates to organizational policies and review processes when necessary.

• Provide physician oversight for quality and performance initiatives by reviewing medical management outcomes, analyzing quality metrics, and engaging in quarterly Quality Committee meetings and reporting.

• Participate in internal audits, accreditation activities, regulatory reviews, and quality improvement initiatives to ensure adherence to organizational standards and ongoing operational excellence.

• Collaborate with operational leadership to ensure that clinical standards are effectively woven into utilization review workflows, fostering efficient, evidence-based, and member-centered medical management.

• Offer clinical consultation and recommendations concerning post-service medical necessity determinations, appeals, and other medically complex cases necessitating physician review.

• Serve as a reliable clinical resource and advisor to physicians, nurses, utilization review staff, and cross-functional business partners by offering education, guidance, and consultation on medical policy and clinical best practices.

• Engage in interdisciplinary committees, physician advisory groups, and organizational meetings to provide clinical insights and support strategic initiatives.

• Cultivate collaborative relationships with internal and external stakeholders to enhance quality outcomes, regulatory compliance, and continuous improvement across medical management programs.

• Execute other duties as assigned.

⛳️ Requirements

• MD or DO degree with a valid, unrestricted medical license.

• Board certification in a recognized specialty.

• Experience in utilization management, medical policy development, and oversight of clinical programs.

• Knowledge of relevant regulations (e.g., CMS, URAC, and state-specific requirements).

• Strong interpersonal, organizational, and analytical abilities.

• Active, unrestricted Texas medical license (full licensure, not an administrative license).

• Must maintain active medical licenses in states requiring physician licensure for utilization reviews. Current priorities include Maryland, New Hampshire, West Virginia, and Texas. Additional state licenses are preferred as business needs develop.

🏝️ Benefits

• Competitive benefits package with generous employer contributions.

• Flexible and remote work options.

• 401k plan with a generous employer match and immediate vesting.

• Opportunities for personal and professional development.

• Supportive family benefits, including paid leave for new family members.

• Companywide philanthropic program, Valenz Communities Connection.