Senior Medical Director – YouthCare

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

📋 Description

• Support the Vice President of Medical Affairs in directing and coordinating medical affairs functions within the business unit.

• Supervise the denials and appeals department.

• May oversee additional medical directors.

• Assume VPMA responsibilities during the absence of the VPMA.

• Provide medical leadership across all areas of utilization management, pharmacy, case management, disease management, cost containment, and medical quality improvement activities.

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

• Facilitate the effective execution of performance improvement initiatives for capitated providers.

• Assist the VPMA in planning and setting goals and policies aimed at enhancing the quality and cost-effectiveness of care and services for members.

• Offer medical expertise in the operation of approved quality improvement and utilization management programs, ensuring compliance with regulatory, state, corporate, and accreditation standards.

• Aid the VPMA in managing physician committees, including their structure, processes, and membership.

• Supervise the activities of physician advisors and other medical directors.

• Leverage the expertise of medical and pharmacy consultants to review complex cases and medical necessity appeals.

• Engage in provider network development and new market expansion as needed.

• Participate in provider profiling initiatives.

• Assist in the creation and implementation of physician education regarding clinical issues and policies.

• Identify utilization review studies and assess adverse trends in the use of medical services, unusual provider practice patterns, and the adequacy of benefit/payment components.

• Recognize clinical quality improvement studies aimed at reducing unwarranted variations in clinical practice through provider profiling to enhance quality and cost of care.

• Collaborate with physicians and other providers to facilitate the implementation of recommendations that improve utilization and healthcare quality.

• Review claims that involve complex, controversial, or new services to determine medical necessity and appropriate payment.

• May establish partnerships with the provider community by developing and implementing medical management programs.

• If necessary, represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.

• Represent the business unit in relevant state committees and other ad hoc committees.

• May oversee all aspects of the Appeals and Denials department, including budgetary, policy, and personnel decisions for the department.

• Work flexible hours to ensure adequate staffing levels and coverage, including weekends and holidays, to meet patient care needs and support case coverage.

⛳️ Requirements

• MD or DO with no restrictions.

• Board Certified in Pediatrics or Family Medicine.

• Must possess a valid license in Illinois.

• Must reside in Illinois.

• At least 7 years of clinical experience in the practice of medicine.

• Management experience is preferred.

• Knowledge of Utilization Management and quality accreditation standards 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.

• Board certification in a medical specialty acknowledged by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services (Certification in Psychiatry specialty is required).

• Current Illinois license as an MD or DO with no restrictions, limitations, or sanctions from government programs.

• A minimum of five (5) years of experience practicing in internal medicine, primary care, or pediatrics is required.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K and stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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