Medical Management - Medical Director

Community Care•Tulsa, OK

12d

About The Position

JOB SUMMARY: The Medical Director provides physician-level clinical review expertise within the health plan’s utilization management, appeals, and clinical governance programs. The Medical Director applies evidence-based clinical judgment to utilization management and appeal determinations and collaborates with interdisciplinary clinical teams to ensure appropriate, consistent, and compliant decision-making across all applicable lines of business, including Medicare Advantage, Marketplace, and Commercial products. This role functions under the direction of the Chief Medical Officer within an established delegation and escalation framework. The Medical Director maintains current, relevant clinical knowledge and expertise, including familiarity with evidence-based clinical guidelines and emerging or novel treatments for the medical and behavioral health conditions, diseases, procedures, and services under review. KEY RESPONSIBILITIES: Applies evidence-based clinical judgment to utilization management and appeal determinations, including medical, behavioral health, and drug-related cases, when physician-level review is required. Maintains current knowledge of evidence-based clinical guidelines and emerging or novel treatments relevant to the medical and behavioral health conditions, diseases, procedures, and services reviewed in utilization management and appeals. Participates in peer-to-peer discussions and secondary reviews with providers to support appropriate utilization management decisions and facilitate medically appropriate care. Supports the consistent interpretation and application of medical policies, clinical guidelines, and utilization management criteria across all lines of business. Collaborates with pharmacists, nurses, and other clinical reviewers to ensure utilization management determinations are rendered by appropriately licensed clinicians acting within scope of practice. Escalates complex, high-risk, or policy-sensitive cases to the Chief Medical Officer as appropriate. Provides clinical input and subject matter expertise to internal clinical committees, quality improvement initiatives, and special projects as assigned. Collaborates with cross-functional departments, including pharmacy, quality improvement, claims, and network management, to support coordinated clinical operations. Supports compliance with applicable federal and state regulations, accreditation standards, and internal policies related to utilization management and appeals. Participates in the review and interpretation of utilization, quality, and clinical performance data to support continuous improvement initiatives. Engages in provider education and communication related to medical policies, evidence-based guidelines, and appropriate care delivery practices. Performs other duties consistent with the role of Medical Director as assigned by the Chief Medical Officer or executive leadership.

Requirements

Strong clinical judgment and analytical skills with the ability to apply evidence-based guidelines to utilization management and appeal determinations
Excellent communication and interpersonal skills, including the ability to conduct peer-to-peer discussions with network providers.
Ability to work collaboratively within a multidisciplinary clinical review environment.
Demonstrated current, relevant clinical expertise in the conditions, treatments, and procedures subject to utilization management and appeal review, including knowledge of evidence-based guidelines and novel or emerging therapies.
Licensed as either a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) from an accredited US medical school
For clinical peer review and appeal peer review, a medical license is the type and scope that permits application of clinical judgement in consideration of an individual member’s clinical needs to render a utilization review determination.
Residency training in an applicable clinical discipline.
Board certification in an ABMS- or AOA-recognized specialty, maintained in good standing.
Possess a current and valid nonrestricted medical license in any United States jurisdiction.
Minimum of five (5) years of post-training clinical practice experience in the physician’s specialty.
Demonstrated experience applying evidence-based clinical judgment in utilization management, medical necessity determinations, peer review, or appeals review within a managed care, health plan, or similar clinical oversight environment.
Demonstrated knowledge of evidence-based clinical guidelines, medical policy interpretation, and utilization management principles.
Ability to apply independent clinical judgment in utilization review and appeal determinations consistent with regulatory and accreditation requirements.
Experience working collaboratively with multidisciplinary clinical teams, including pharmacists and nursing staff.

Nice To Haves

Knowledge of regulatory and accreditation standards applicable to managed care utilization management and appeals processes preferred.
Familiarity with health plan accreditation standards (e.g., URAC, NCQA) and applicable regulatory requirements preferred.
Comfort working with utilization, quality, and claims-based data to support clinical decision-making preferred.

Responsibilities

Applies evidence-based clinical judgment to utilization management and appeal determinations, including medical, behavioral health, and drug-related cases, when physician-level review is required.
Maintains current knowledge of evidence-based clinical guidelines and emerging or novel treatments relevant to the medical and behavioral health conditions, diseases, procedures, and services reviewed in utilization management and appeals.
Participates in peer-to-peer discussions and secondary reviews with providers to support appropriate utilization management decisions and facilitate medically appropriate care.
Supports the consistent interpretation and application of medical policies, clinical guidelines, and utilization management criteria across all lines of business.
Collaborates with pharmacists, nurses, and other clinical reviewers to ensure utilization management determinations are rendered by appropriately licensed clinicians acting within scope of practice.
Escalates complex, high-risk, or policy-sensitive cases to the Chief Medical Officer as appropriate.
Provides clinical input and subject matter expertise to internal clinical committees, quality improvement initiatives, and special projects as assigned.
Collaborates with cross-functional departments, including pharmacy, quality improvement, claims, and network management, to support coordinated clinical operations.
Supports compliance with applicable federal and state regulations, accreditation standards, and internal policies related to utilization management and appeals.
Participates in the review and interpretation of utilization, quality, and clinical performance data to support continuous improvement initiatives.
Engages in provider education and communication related to medical policies, evidence-based guidelines, and appropriate care delivery practices.
Performs other duties consistent with the role of Medical Director as assigned by the Chief Medical Officer or executive leadership.