Medical Director

About the Role

This is a remote role providing support to commercial and worker’s compensation self-funded clients seeking cost-effective resolution of their members' claims. You will lead and develop our team while maturing the program, fostering a culture focused on service, quality healthcare, and medical cost containment for the benefit of clients and their members.

Responsibilities

• Creates and updates medical policies and procedures in conjunction with associate medical directors and other clinical staff, ensuring consistency and compliance with generally accepted medical standards and guidelines.
• Provides clinical support for all areas of Clinical Services.
• Reviews medical files and makes coverage and medical necessity determinations using good judgment combined with third-party and proprietary medical guidelines.
• Identifies, critiques, and utilizes 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.
• Advises team nurses on the 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.
• Informs the UR Nurse of certification decisions within appropriate time frames as guided by URAC, ERISA, or state regulations.
• Supports training of nurses and coordinators to improve their knowledge, independence, and understanding.
• Serves as a medical expert for care management and population health; reviews and evaluates cases with review nurses to ensure medical care meets acceptable standards.
• Reviews and resolves retro reviews, appeals, and grievances related to medical quality of care and actively participates in the grievance and appeals processes.
• Along with the nurse supervisor and manager, identifies opportunities for improvement and collaborates to enhance team performance.
• Makes appropriate outreach to community and academic-based treating providers to discuss cases.
• Interacts telephonically and personally with employees/departments to maintain effective communication, support, and a positive work atmosphere.
• Opportunity to interact with sales and account management supporting client needs.
• Collaborates with other departments (e.g., Member Services, Provider Services, Claims, and Contracting) to improve performance.
• Attends departmental committees as assigned.
• Performs other duties as required by the business.
• Maintains proper credentialing, state licenses, and any special certifications or requirements necessary to perform the job.

Requirements

• Board certification 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.
• Case management and/or Population Health Management experience desirable.
• 3+ years of prior clinical practice in either an office or hospital-based setting with boards from a wide range of Internal Medicine specialties. Must be self-motivated to stay up to date on a broad range of medical services using resources such as MCG guidelines, specialty society guidelines, UpToDate, and others to analyze existing cases.
• Specialty training in addition to a first board certification highly desirable.
• Current, unrestricted clinical license(s).
• Board certification by the American Board of Medical Specialties or American Board of Osteopathic Specialties, in Internal Medicine or Pediatrics or a subspecialty of Internal Medicine or Pediatrics, is required for MD or DO reviewers.
• Ability to communicate clearly and concisely, both verbally and in writing.
• Knowledge of evidence-based medical guidelines (nationally recognized standards of healthcare), utilization management, quality improvement, and other medical management functions.
• Strong interpersonal and communication skills to support a team-based approach.
• Proficient computer skills and knowledge of basic programs.

About the Company

Brighton Health Plan Solutions, LLC is committed to improving how healthcare is accessed and delivered. Our team fosters a diverse and welcoming culture focused on encouragement, respect, and increasing diversity, inclusion, and a sense of belonging. We partner with self-insured employers, Taft-Hartley Trusts, health systems, providers, and other TPAs to solve today’s healthcare challenges with flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, proprietary provider networks, and an innovative technology platform. As a healthcare enablement company, we provide customizable tools to enhance the member experience, improve health outcomes, and achieve healthcare goals.

Mission: Transform the health plan experience—how healthcare is accessed and delivered—by bringing outstanding products and services to our partners.

Vision: Redefine healthcare quality and value by aligning the incentives of our partners in powerful and unique ways.

DEI Purpose Statement: At BHPS, we encourage all team members to bring their authentic selves to work with all their unique abilities. We respect how you experience the world and welcome the fullness of your lived experience into the workplace. We are building, nurturing, and embracing a culture focused on increasing diversity, inclusion, and a sense of belonging at every level.