Medical Director
About The Position
The Medical Director is a highly experienced medical professional responsible for providing clinical expertise, oversight, and strategic guidance across medical management functions. This role supports complex clinical decision-making including appeals, rescissions, and grievance reviews, while also partnering with legal, product and actuarial teams. In addition, this role contributes to advancing innovation within Medical Management, including supporting the adoption of artificial intelligence (AI) and process improvements to enhance the efficiency, accuracy, and scalability of misrepresentation and clinical review processes. The position proactively partners with cross-functional teams to help move initiatives forward and maintain alignment on priorities, timelines, and expected outcomes.
Requirements
- 4 year Bachelors Degree (Required)
- MD or DO (Required)
- 8 or more years of experience (Required)
- Clinical experience appropriate to the conditions under review, including ability to perform peer-level review of medical necessity and pre-existing condition determinations
- Active and unrestricted license to practice medicine (Required)
Nice To Haves
- Experience working with health insurance preferred
- MS Word, PowerPoint and Excel spreadsheet skills
- Training and education skills
- Effective communication skills, verbal and written
- Ability to handle shifting priorities
- Effective presentation skills including the ability to present complex medical risk information
Responsibilities
- Provides clinical oversight and governance for the medical review program, including appeals, rescission, and grievance panel processes
- Conducts comprehensive clinical reviews for first and second-level appeals, including Department of Insurance (DOI) complaints
- Evaluates complex medical cases to ensure consistency with policy provisions, clinical guidelines, and regulatory requirements
- Provides expert clinical judgment in high-risk or sensitive determinations
- Provides independent clinical judgement in support of coverage determinations, free from claims or financial influence
- Supports alignment and consistency across appeal outcomes and internal review processes
- Leads clinical evaluation and decision-making for rescission cases and member grievances
- Ensures appropriate application of underwriting intent and policy interpretation in misrepresentation reviews
- Partners with legal on complex or escalated cases
- Partners with legal to ensure compliance with applicable state and federal requirements governing adverse benefit determinations, grievance processes, and clinical review standards
- Documents clinical rationale supporting determinations in a manner suitable for regulatory review, audits and litigation
- Identifies opportunities to improve upstream underwriting and risk selection practices
- Supports quality assurance and consistency of TPA decision-making
- Partners with product management and actuarial teams to inform product design and risk selection strategies
- Identifies trend and provides clinical insight on emerging risks, market trends, and competitive positioning
- Contributes to and helps advance initiatives to integrate AI and/or automation into medical review workflows
- Proactively identifies and raises opportunities to streamline processes and improve efficiency
- Partners with stakeholders to help maintain alignment on priorities, timelines, and expected outcomes
Benefits
- monthly connectivity reimbursement
- laptop, monitors, headset, keyboard, and mouse
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What This Job Offers
Job Type
Full-time
Career Level
Senior
