Medical Director Medical Policy

About the role

Provides clinical program leadership and develops, implements and approves policies within recognized area of responsibility.

Responsibilities

• Develop and maintain medical policy
• Establish rationale for approving inquiries and appeals
• Assist with clinical research, writing documents, and documenting decisions
• Provide utilization management for prior authorization procedures
• Review cases and make decisions based on medical policy
• Provide clinical support to various areas of the organization
• Process requests for clarification, interpretation, or questions about policy or benefits
• Review potential impacts of clinical matters
• Serve as clinical resource and subject matter expert to both clinical and non-clinical staff
• Perform clinical reviews and conduct peer to peers
• Participate in JUMP committee meetings

Qualifications

• Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O.) required
• Seven (7) years clinical practice experience
• Current unrestricted state of Michigan Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) license
• Board certified or board eligible and working towards certification in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy
• Proven leadership, problem solving, and the ability to manage multiple priorities
• Strong teaching and communication skills
• Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals
• Demonstrated skill with Microsoft Office Suite and web-based programs
• Understanding of health plan functions related to utilization, care, and quality management
• Other related skills and/or abilities may be required to perform this job

Department Summary / Preferences

• Specialty Care Knowledge is preferred
• Medical Policy Experience is a plus