Medical Director

About the Role

This position is part of a physician team and ensures utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of requested treatments or services. Depending on the case, telephonic peer-to-peer discussions may be required. The role ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations. Additionally, the incumbent serves as the physician member of a multidisciplinary team for case and disease management, advising on high-risk cases and participating in protocol and guideline development.

Responsibilities

• Conduct electronic reviews of escalated cases against medical policy criteria, including telephonic peer-to-peer discussions, to determine medical necessity and appropriateness.
• Complete initial determinations, review appeals and grievances, and perform other assigned reviews.
• Compose clear and concise rationales for member and provider determination notifications while adhering to compliance standards (NCQA, URAC, CMS, DOH, DOL).
• Ensure all aspects of the medical management process align with community standards of care.
• Participate as a member of the multidisciplinary Case and Disease Management (CMDM) team, attending huddles and grand rounds.
• Advise the multidisciplinary team on cases requiring physician expertise.
• Contribute to the development of protocols and guidelines to ensure consistency in the review process.
• Actively manage or participate in projects requiring a physician subject matter expert.
• Perform other duties as assigned.

Requirements

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) degree.
• Active medical state licensure; additional state licensure(s) may be required based on business need.
• Board certification at least once in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards.
• 5 years of clinical, direct patient care experience (hospital, outpatient, or private practice).

Preferred Qualifications

• Master’s Degree in Business Administration/Management or Public Health.
• 1 year of experience in medical management within a health insurance plan.
• Strong knowledge of the managed care industry.

Skills

• Critical Thinking
• Case Management
• Customer Service
• Oral & Written Communication
• Collaboration
• Listening
• Telephone Skills
• General Computer Skills
• Clinical Software
• Managed Care

Working Conditions

• Office-based position.
• Occasional teaching/training of others.
• Travel required (0% - 25%), including between office sites or work locations.
• Rarely works primarily out-of-office (e.g., sales).
• Physical work site required.
• Lifting: up to 10 pounds (constantly), 10 to 25 pounds (rarely), 25 to 50 pounds (rarely).

Pay

Base pay range: $227,600.00 – $385,000.00. Pay is determined by qualifications, experience, expected contributions, internal peer equity, market considerations, and potential geographic differentials for certain locations.