Medical Director

Job Description

Pay Range: $140hr - $145hr

• Ability to meet regulatory and compliance timelines.
• Strong knowledge of utilization management, medical necessity determinations, and quality standards.

• Experience handling utilization management determinations, appeals, and grievances.
• Experience reviewing clinical services and quality incidents requiring physician involvement.
• Experience collaborating on medical policy development and technology assessments.

• Perform utilization management initial determinations, appeals, and grievance reviews within regulatory and accreditation guidelines.
• Review serious clinical services cases and quality incidents requiring physician oversight.
• Provide medical necessity determinations supporting investigations related to fraud, waste, and abuse.
• Collaborate on development and review of medical policies.
• Assess new, emerging, and existing technologies for coverage appropriateness.
• Partner with clinical and operational leaders to manage medical service expenditures.
• Collaborate with quality, finance, medical management, and business teams to improve the quality and cost efficiency of care.
• Provide consultation and educational support to network clinicians and staff.
• Develop and deliver presentations on clinical topics relevant to members and providers.
• Represent the organization in external forums and committees as needed.
• Communicate and collaborate with physicians, hospital leaders, and vendors regarding enrollee care.
• Monitor performance metrics and audit results to drive compliance and continuous improvement.
• Build strong relationships that support a people-first culture.
• Integrate diversity, equity, and inclusion as a guiding principle.
• Perform additional duties as assigned.

• Strong leadership and stakeholder collaboration skills.
• Experience working with regulatory and accreditation bodies.

• Clinical decision-making and medical policy expertise.
• Utilization management and quality oversight.
• Strong communication and presentation skills.
• Relationship building and stakeholder engagement.
• Analytical and performance improvement skills.

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO).