Medical Director – Utilization Management & Worker's Compensation

Council Capital•Nashville, TN

10h

About The Position

Council Capital is a healthcare-focused private equity firm based in Nashville, Tennessee, managing more than $350 million in committed capital. It invests in lower middle market healthcare companies and supports founders and leadership teams through its CEO Council, Strategic Healthcare Investors, and internal Value Creation Team. The Medical Director provides physician leadership for utilization management and workers’ compensation-related work. The role serves as the primary physician resource for utilization-management decisions, escalations, and complex case reviews; provides clinical oversight for medical-necessity determinations; and supports concurrent and retrospective reviews as needed. The Medical Director also conducts peer-to-peer reviews with payers, works with internal teams to improve payer communications and outcomes, guides providers on clinical documentation, and contributes clinical insight to audits, denial trends, utilization strategy, and risk mitigation. This is an active, ownership-oriented role requiring sound clinical judgment and engagement. It is not a full-time practicing clinician position, nor is it purely academic, advisory-only, or compliance-only.

Requirements

MD or DO with an active, unrestricted medical license.
Board certification in a relevant specialty.
Prior experience in Utilization Management, Physician Advisory, Medical Review, or a similar role.
Strong understanding of medical necessity, payer criteria, and utilization standards.
Ability to communicate effectively with clinicians and non-clinical leaders.

Nice To Haves

Experience working with commercial payers and managed care organizations.
Prior peer-to-peer review experience with documented success overturning denials.
Experience in outpatient, post-acute, or multi-site healthcare services environments.
Exposure to healthcare services organizations operating in growth or private-equity-backed environments.

Responsibilities

Serve as the primary physician resource for utilization-management decisions, escalations, and complex case reviews.
Provide clinical oversight and guidance for medical-necessity determinations.
Support concurrent and retrospective review processes as needed.
Conduct physician-to-physician reviews with payers to support authorization approvals and overturn denials.
Partner with Utilization Management and Revenue Cycle teams to improve payer communication strategies.
Identify payer-specific trends and opportunities to improve outcomes.
Educate providers on documentation best practices related to medical necessity and payer criteria.
Identify recurring documentation gaps and implement corrective guidance.
Support audit preparation and response from a clinical perspective.
Partner with Case Management, Utilization Management leadership, Revenue Cycle, Compliance, and Operations.
Provide insights and recommendations based on denial trends and utilization data.
Participate in leadership discussions related to utilization strategy and risk mitigation.
Drive alignment across providers and payers and make timely, confident, data-informed decisions.