Senior Medical Director – Precertification

This is a fully remote position, open to applicants in Connecticut, +4 more states.

📋 Description

• Provides strategic guidance, professional oversight, and leadership throughout the precertification process and additional clinical operations.

• Partners with executive leadership to formulate and execute strategies that align with healthcare objectives, enhance processes, promote innovation, and positively influence members and providers.

• Utilizes medical and operational expertise to develop and align the company's objectives with clinical strategies and regulatory requirements.

• Works with cross-functional leaders to shape and advance the clinical operations strategy and initiatives, ensuring optimal quality and efficiency.

• Establishes clinical standards and supervises clinical governance frameworks to guarantee patient safety and high-quality care.

• Directs the development of clinical processes and programs, such as clinical protocols, guidelines, treatment pathways, and training materials.

• Oversees the operations of the Medicare Precertification MD Team, in accordance with governing policies and procedures.

• Guides teams through Medicare audits and ongoing audit readiness.

• Keeps abreast of pertinent scientific evidence, industry standards, and regulatory changes to ensure organizational compliance and relevance.

• Builds and maintains relationships with key stakeholders, including government agencies, providers, and professional organizations.

• Develops and continuously monitors key metrics to evaluate the performance of strategic initiatives and processes, making necessary adjustments.

• Provides mentorship, professional development opportunities, and support to physicians, encouraging their growth and ensuring a cohesive, skilled medical team.

• Collaborates with legal and compliance teams to ensure that developed clinical processes and solutions adhere to all relevant regulatory requirements.

⛳️ Requirements

• MD or DO with an active, unrestricted license and board certification in an ABMS or AOA recognized specialty.

• Minimum of 5 years of direct patient care experience in a clinical environment.

• At least 5 years of experience in utilization management, precertification, or related roles.

• In-depth knowledge of Medicare regulations, including NCDs, LCDs, Medicare manuals, and regulatory references.

• Proven capability to interpret and apply Medicare guidelines to complex case reviews and decision-making processes.

• Advanced understanding of medical coding standards, compliance requirements, and oversight of coding practices.

• Demonstrated leadership in managing teams, driving process improvements, and ensuring regulatory compliance.

• Successful history of guiding teams through Medicare audits and maintaining audit readiness.

• Strong interpersonal, communication, and cross-functional stakeholder management abilities.

• Dedication to developing talent and fostering an inclusive, high-performing team culture.

🏝️ Benefits

• Medical, dental, and vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources, based on eligibility.