Medical Director – Utilization Management & Worker's Compensation

Council Capital•Nashville, TN

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, including control and minority positions in businesses with enterprise values between $10 million and $100 million. Its Council Model supports founders and leadership teams through a CEO Council, Strategic Healthcare Investors, and an internal Value Creation Team focused on talent, systems, and strategy. 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 of medical necessity determinations; and supports review processes as needed. The Medical Director also conducts peer-to-peer reviews with payers, works with utilization management and revenue cycle teams to improve payer communication, and identifies payer trends and opportunities to improve outcomes. The position supports provider education on documentation practices related to medical necessity and payer criteria, identifies recurring documentation gaps, and assists with audit preparation and response. It collaborates with Case Management, utilization management leadership, Revenue Cycle, Compliance, and Operations, and provides recommendations based on denial trends and utilization data. This is an active, ownership-oriented role, not a purely academic or advisory-only position, a full-time practicing clinician role, or a compliance-only function.

Requirements

MD or DO with an active, unrestricted medical license.
Board certified 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 decision-making, 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.