Position Title: Medical Director
Work Location: Remote - Nationally Sourced
Assignment Duration: 6 months with potential to extend or convert
Work Schedule: 8 am - 5 pm in candidate's time zone (EST, CST, PST)
Position Summary:
* Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. Key Responsibilities:
* Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
* Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.
* Supports effective implementation of performance improvement initiatives for capitated providers.
* Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
* Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
* Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
* Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
* Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
* Participates in provider network development and new market expansion as appropriate.
* Assists in the development and implementation of physician education with respect to clinical issues and policies.
* Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
* Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
* Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
* Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
* Develops alliances with the provider community through the development and implementation of the medical management programs.
* As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.
* Represents the business unit at appropriate state committees and other ad hoc committees.
* May be required to work weekends and holidays in support of business operations, as needed.
* Performs other duties as assigned
* Complies with all policies and standards Qualification & Experience:
* Medical Doctor or Doctor of Osteopathy
* Utilization Management experience
* 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 (Psychiatry if Behavioral Health)
* Current state medical license without restrictions
* Course work in Health Admin, Financing, Insurance preferred
* Experience treating or managing care for culturally diverse population preferred
Candidate Requirements |
Education/Certification |
Required: Medical Doctor or Doctor of Osteopathy.
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. |
Preferred: |
Licensure |
Required: need to be licensed |
Preferred: |
- Years of experience required
- Disqualifiers
- Best vs. average
- Performance indicators
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Must haves:
UM experience (minimum of 1 year experience)
Nice to haves:
Medicare UM experience
Extensive state licensing
Disqualifiers:
Not meeting the board certification
Performance indicators:
Production capacity around the 45 cases per day
Quality of the review
A strong candidate would meet the following:
- Clinical Expertise: Board-certified physician with active practice experience.
- UM Proficiency: Proven ability to handle high-volume case reviews efficiently and accurately.
- Behavioral Health Experience: Especially valuable if applying for roles requiring psychiatry certification.
- Tech Savvy: Comfortable using EMR systems and collaborating virtually.
- Adaptability: Can work independently in a remote setting while engaging with a dynamic team.
- Regulatory Knowledge: Familiarity with accreditation standards and state-specific requirements.
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