Medical Director

Brighton Health Plan Solutions, LLC•Chapel Hill, NC

36d•Hybrid

About The Position

Brighton Health Plan Solutions, a full-service health plan administrator, is looking for a part-time board-certified physician with interest and experience in managed care utilization and case management to support our team of nurses, social workers, and coordinators. You will be a leader of the team making medical necessity and benefit coverage determinations and provide support and guidance to the case management programs. You have a passion to make healthcare more effective and affordable. The position can be remote, or on-site in our New York office. The Medical Director will be responsible for providing support for our Commercial and Worker’s Compensation self-funded clients seeking cost-effective resolution of their members’ claims. Your interest and help leading and developing our team and maturing the program only makes the opportunity more rewarding. We have been in business for 25 years and leading by example you will help create a culture focused on service, support of quality healthcare service, and medical cost containment for the benefit of our clients and their members.

Requirements

Board certified MD or DO, with an excellent understanding of the utilization and case management process.
3 years' experience working in a managed care environment supporting utilization management and case review with medical necessity determinations.
3 + years of prior clinical practice with boards from any of a wide range of specialties so long as you are self-motivated to stay up to date on a broad range of medical services using resources. such as mcg guidelines, specialty society guidelines, Up-To-Date and other resources to analyze existing cases.
Current, unrestricted clinical license(s).
Board certification by American Board of Medical specialties or American Board of Osteopathic Specialties is required for MD or DO reviewer with a specialty in Orthopedic Surgery (preferred) or General Surgery.
Ability to communicate clearly and concisely, both verbally and in writing.
Knowledge of evidence-based medical guidelines (nationally recognized standards of health care), utilization management, quality improvement and other medical management functions.
Good interpersonal and communication skills to support the team approach.
Demonstrated computer skills & telephonic skills.

Nice To Haves

Specialty training in addition to a first board certification highly desirable.

Responsibilities

Provides clinical support for all areas of Medical Affairs.
Review medical files and make coverage and medical necessity determinations using good judgement combined with 3rd party and proprietary medical guidelines.
Advises team nurses on appropriateness of care and services through the care continuum including hospitals, skilled nursing facilities, and home care to ensure quality, cost-efficiency and continuity of care.
Serves as medical expert for care management; reviews and evaluates cases with review nurses; ensures medical care provided meets the standards for acceptable medical care.
Reviews and resolves grievances related to medical quality of care and actively participates in the functioning of the plan’s grievance and appeals processes.
Along with the nurse supervisor and manager, identify opportunities for improvement and collaborate to enhance team performance.
Makes appropriate outreach to community and academic based treating providers wanting to discuss cases.
Identify, critique, and utilize criteria and resources such as national, state, and professional association guidelines and peer reviewed literature to support sound and objective decision making and rationales in reviews.
Collaborate with other departments, i.e. Member Services, Provider Services, Claims and Contracting, to improve performance.
Support the nurses and coordinators to improve their knowledge, independence, and understanding
Performs other duties as required by the business.
Opportunity to interact with sales and account management supporting client needs.
Maintain proper credentialing and state licenses and any special certifications or requirements necessary to perform the job.