National Medical Director

This is a fully remote position, open to applicants in Arizona, +6 more states.

📋 Description

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

• Provide medical leadership for activities related to utilization management, cost containment, and enhancements in medical quality.

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

• Support performance improvement initiatives for capitated providers.

• Assist in establishing goals and policies aimed at enhancing the quality and cost-effectiveness of care and services.

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

• Assist with physician committees, including structuring, processes, and membership considerations.

• Conduct regular rounds to evaluate and coordinate care for high-risk patients in collaboration with care management teams.

• Work alongside 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.

• Facilitate physician education on clinical matters and relevant policies.

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

• Identify clinical quality improvement studies aimed at minimizing unwarranted variations in clinical practices.

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

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

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

• Represent the business unit in front of local and national audiences regarding medical philosophy, policies, and related matters as required.

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

⛳️ Requirements

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

• Actively engaged in medical practice.

• 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.

• Current state license as an MD or DO without restrictions, limitations, or sanctions from government programs.

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

• Certification in Internal or Family Medicine is 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.

• May be required to work weekends and holidays to support business operations, as necessary.

🏝️ Benefits

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work arrangements with options for remote, hybrid, field, or office schedules.

• Competitive salary.