Medical Director

Provide support to commercial and worker’s compensation self-funded clients seeking cost-effective resolution of their members' claims. Lead and develop the team while maturing the program, fostering a culture focused on service, quality healthcare, and medical cost containment for clients and their members.

Responsibilities

• Create and update 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.
• Provide clinical support for all areas of Clinical Services.
• Review medical files and make coverage and medical necessity determinations using good judgment combined with third-party and proprietary medical guidelines.
• 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.
• Advise 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.
• Inform the UR Nurse of certification decisions within appropriate time frames as guided by URAC, ERISA, or state regulations.
• Support the training of nurses and coordinators to improve their knowledge, independence, and understanding.
• Serve as a medical expert for care management and population health; review and evaluate cases with review nurses to ensure medical care meets acceptable standards.
• Review and resolve retro reviews, appeals, and grievances related to medical quality of care and actively participate in the plan’s grievance and appeals processes.
• Along with the nurse supervisor and manager, identify opportunities for improvement and collaborate to enhance team performance.
• Make appropriate outreach to community and academic-based treating providers to discuss cases.
• Interact telephonically and personally with employees/departments to maintain effective communication, support, and a positive work atmosphere.
• Interact with sales and account management to support client needs.
• Collaborate with other departments (e.g., Member Services, Provider Services, Claims, and Contracting) to improve performance.
• Attend departmental committees as assigned.
• Perform other duties as required by the business.
• Maintain proper credentialing, state licenses, and any special certifications or requirements necessary to perform the job.

Requirements

• Board certified 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, and UpToDate.
• 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, Pediatrics, or a subspecialty of Internal Medicine or Pediatrics (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 culture is diverse, welcoming, and focused on encouragement, respect, and fostering 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, 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. Together with our trusted partners, we transform the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.

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

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

Benefits

• Annual Salary Range: $200,000–$235,000 (bonus eligible).