Medical Director

Essential Job Responsibilities

• Utilization Management Review
• Review and evaluate prior authorization requests submitted by staff pharmacists or clinical team members that require physician review.
• Conduct clinical medical necessity reviews of physician or member at the first and second levels, as appropriate.
• Serve as a peer-to-peer consulting physician as needed, when regulations allow.
• Provide medical rationale and documentation supporting appeal decisions.
• Coordinate with and audit third-party external review agencies to ensure timely and accurate completion of third-level appeals.
• Collaborate with and audit external reviewers to ensure fair, evidence-based determinations.
• Utilization Management Compliance
• Support Utilization Management operations by providing clinical expertise for formulary-related decisions, coverage determinations, and other benefit-aligned activities.
• Affiliate with responsibilities related to formulary management, utilization review processes, and related initiatives (e.g., UM policies, clinical criteria updates).
• Serve as a member of the internal Utilization Management Committee.
• Collaborate with Legal and Compliance teams to ensure adherence to all applicable state and federal regulations governing medical director oversight and utilization management practices.
• Participate in internal audits, compliance reviews, and quality improvement initiatives.
• Support documentation and process updates to ensure regulatory readiness.
• Regulatory Oversight
• Serve as the Medical Director of record for multiple states for the utilization management review program.
• In coordination with Legal, maintain up-to-date knowledge of regulatory requirements related to medical necessity review, prior authorization, and appeals.
• Stakeholder Collaboration
• Serve as a thought leader on member health & welfare, benefit design and new lines of business.
• Provide insight to clients/brokers regarding coverage determination as needed.

Required Skills / Experience

• Doctor of Medicine or Osteopathy from an accredited institution
• Active, unrestricted license to practice medicine
• Multiple State licenses preferred
• 5+ years of professional medical experience after completing residency training
• Demonstrated experience in utilization management and prior authorization required
• Pharmacy knowledge required; specialty drug utilization experience preferred
• Strong analytical skills and problem-solving skills
• Ability to translate clinical insights into business strategies and client solutions
• Exceptional collaborative partner with internal and external stakeholders
• Excellent written, verbal, and presentation skills
• Proficiency in Microsoft Office
• Occasional travel required