Senior Medical Director

This is a fully remote position, open to applicants in New Hampshire.

📋 Description

• Assist the Vice President of Medical Affairs in leading and coordinating medical affairs activities for the business unit.

• Supervise the denials and appeals department.

• Act as the clinical executive leader, representing the health plan both internally and externally.

• Manage clinical escalations, state fair hearings, and health plan advocacy with the New Hampshire Department of Health and Human Services.

• Provide medical leadership in areas such as utilization management, pharmacy, case management, disease management, cost containment, and medical quality improvement.

• Conduct utilization review, quality assurance, and medical review of complex, controversial, or experimental services.

• Support performance improvement initiatives for capitated providers.

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

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

• Facilitate the structure, processes, and membership of physician committees.

• Oversee physician advisors and other medical directors.

• Engage medical and pharmacy consultants for complex cases and medical necessity appeals.

• Participate in provider network development, market expansion, and provider profiling initiatives.

• Develop and implement educational programs for physicians on clinical issues and policies.

• Identify utilization review and clinical quality improvement studies while assessing adverse utilization trends and provider practice patterns.

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

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

• Establish provider-community alliances through medical management programs.

• Represent the business unit in public forums and state or ad hoc committees.

• Oversee budgetary, policy, and personnel decisions for the appeals and denials department.

• Perform additional duties as assigned and adhere to all policies and standards.

⛳️ Requirements

• Medical Doctor or Doctor of Osteopathy degree.

• Over 7 years of clinical experience in the practice of 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.

• Possession of a current state license as an MD or DO with no restrictions, limitations, or sanctions from government programs.

• Actively engaged in practicing medicine.

• The Senior Medical Director must reside in New Hampshire or be willing to relocate.

• Strongly preferred experience in managed care or ACO leadership.

• Management experience is preferred.

• Preferred knowledge of Utilization Management and quality accreditation standards.

• Active American Board Certification in Internal or Family Medicine is preferred.

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

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

• Must be willing to work flexible hours, including weekends and holidays, as necessary.

🏝️ Benefits

• Competitive compensation.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement opportunities.

• Paid time off in addition to holidays.

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

• Additional incentives may be included in the total compensation package.