Medical Director – Utilization Management, Worker's Compensation

This is a fully remote position, open to applicants in Florida, +1 more state.

📋 Description

• Act as the main physician resource for decision-making in utilization management, handling escalations and intricate case evaluations.

• Offer clinical oversight and direction for assessments of medical necessity.

• Assist with concurrent and retrospective review processes as required.

• Perform physician-to-physician consultations with payers to facilitate authorization approvals and challenge denials.

• Collaborate with Utilization Management and Revenue Cycle teams to enhance communication strategies with payers.

• Recognize payer-specific trends and opportunities to enhance outcomes.

• Educate providers about best practices in documentation related to medical necessity and payer requirements.

• Identify persistent documentation deficiencies and apply corrective measures.

• Assist with audit preparation and responses from a clinical standpoint.

• Partner with Case Management, Utilization Management leadership, Revenue Cycle, Compliance, and Operations.

• Provide insights and recommendations informed by denial trends and utilization statistics.

• Engage in leadership discussions regarding utilization strategies and risk mitigation.

⛳️ Requirements

• MD or DO with an active and unrestricted medical license.

• Board Certified in a pertinent specialty.

• Previous experience in Utilization Management, Physician Advisory, Medical Review, or a related role.

• Strong comprehension of medical necessity, payer criteria, and utilization standards.

• Proficient in effective communication with both clinical and non-clinical leaders.

• Experience with commercial payers and managed care organizations is preferred.

• Previous peer-to-peer review experience with a successful track record of overturning denials is preferred.

• Experience in outpatient, post-acute, or multi-site healthcare services settings is preferred.

• Familiarity with healthcare service organizations in growth or private equity-backed environments is preferred.

🏝️ Benefits

• Part-time employment.

• Remote work opportunity.

• Chance to collaborate with Council Capital and its portfolio companies.

• Work alongside the CEO Council, Strategic Healthcare Investors, and the internal Value Creation Team.