National Medical Director

This is a fully remote position, open to applicants in Illinois, +6 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 containment, 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 efforts for capitated providers.

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

• Offer medical expertise for quality improvement and utilization management programs.

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

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

• Collaborate 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.

• Develop and execute physician education on clinical issues and policies.

• Identify studies for utilization review, adverse trends in utilization, unusual practice patterns by providers, and issues regarding benefit/payment adequacy.

• Recognize clinical quality improvement studies aimed at decreasing unwarranted variations in clinical practice.

• Interface 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 ensure appropriate payment.

• Foster provider-community alliances through medical management programs.

• Represent the business unit before local and national stakeholders, state committees, and ad hoc committees as needed.

⛳️ Requirements

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

• Actively practicing medicine.

• 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.

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

• Active certification in Internal Medicine or Family Medicine preferred.

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

• Preferred experience in treating or managing care for a culturally diverse population.

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

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase plans.

• Tuition reimbursement program.

• Paid time off in addition to holidays.

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

• Additional incentive forms may be included in total compensation.

• Commitment to equal opportunity employment.

• Qualified applicants with arrest or conviction records will be considered per the LA County Ordinance and the California Fair Chance Act.