Medical Director, Pharmacy

This is a fully remote position, open to applicants in Arizona, +10 more states.

📋 Description

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

• Provide medical leadership for utilization management, cost efficiency, and initiatives aimed at improving medical quality.

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

• Support performance improvement initiatives for capitated care providers.

• Aid in setting goals and policies to enhance the quality and cost-effectiveness of care and services.

• Offer medical expertise for quality improvement and utilization management programs in line with regulatory, state, corporate, and accreditation standards.

• Assist with the structure, processes, and membership of physician committees.

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

• Partner 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.

• Support physician education regarding clinical topics and policies.

• Identify utilization review studies and assess adverse utilization patterns, unusual provider practices, and benefit/payment adequacy.

• Identify clinical quality improvement projects to decrease unwarranted variation and enhance care quality and costs.

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

• Review claims for complex, controversial, unusual, or new services to determine medical necessity and appropriate payment.

• Develop alliances within the provider community through medical management programs.

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

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

• Work on weekends and holidays as required to support business operations.

⛳️ Requirements

• Medical Doctor or Doctor of Osteopathy.

• Actively engaged in the practice of medicine.

• 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.

• Possession of a current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

• Experience in Utilization Management and familiarity with quality accreditation standards is preferred.

• Certification in Internal or Family Medicine is advantageous.

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

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

• May need to work weekends and holidays as required to support business operations.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K plan.

• Stock purchase options.

• Tuition reimbursement opportunities.

• Paid time off along with holidays.

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

• Additional incentives may be included in total compensation.

• Equal opportunity employer dedicated to promoting diversity.