Medical Director Jobs

About The Position

Requirements

• Medical Doctor (MD) or Doctor of Osteopathy (DO).
• Board certification in Psychiatry is required.
• Board certification by the American Board of Psychiatry and Neurology is required for the Behavioral Health role.
• Current state medical license as an MD or DO without restrictions, limitations, or sanctions from government programs.

Nice To Haves

• Payer or managed-care experience; this is heavily preferred.
• Utilization Management experience and knowledge of quality accreditation standards.
• Actively practicing medicine.
• Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management.
• Experience treating or managing care for a culturally diverse population.

Responsibilities

• Provide medical leadership for utilization management, cost containment, and medical quality improvement activities.
• Perform medical reviews related to utilization review and quality assurance, including reviews of complex, controversial, or experimental medical services, ensuring timely and quality decision-making.
• Support implementation of performance-improvement initiatives for capitated providers.
• Assist the Chief Medical Director in planning and establishing goals and policies to improve care and service quality and cost-effectiveness for members.
• Provide medical expertise in operating approved quality-improvement and utilization-management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Assist the Chief Medical Director with physician committee structure, processes, and membership.
• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care-management teams to optimize outcomes.
• Collaborate with clinical teams, network providers, the appeals team, and medical and pharmacy consultants to review complex cases and medical-necessity appeals.
• Participate in provider-network development and new-market expansion as appropriate.
• Assist with developing and implementing physician education on clinical issues and policies.
• Identify utilization-review studies and evaluate adverse utilization trends, unusual provider practice patterns, and the adequacy of benefit and payment components.
• Identify clinical quality-improvement studies to reduce unwarranted variation in clinical practice and improve quality and cost of care.
• Work with physicians and other providers to implement recommendations that improve utilization and healthcare quality.
• Review claims involving complex, controversial, unusual, or new services to determine medical necessity and appropriate payment.
• Develop alliances with the provider community through medical-management programs.
• Represent the business unit before local and national publics on medical philosophy, policies, and related issues as needed.
• Represent the business unit at appropriate state and ad hoc committees.
• Work weekends and holidays as needed to support business operations.

Benefits

• Competitive pay
• Health insurance
• 401(k)
• Stock purchase plans
• Tuition reimbursement
• Paid time off and holidays
• Flexible approach to work, with remote, hybrid, field, or office work schedules