Medical Director - Priority Health

We are the second largest and fastest growing health plan in Michigan focused on improving the health and lives across the state. As part of the Corewell Health system, our team members have a unique ability to grow and advance their career while maintaining their seniority and benefits.

About the role

This position is critical to Priority Health's mission of improving health, inspiring hope and saving lives as we partner with medical communities. The Medical Director will apply evidence-based utilization review processes and sound clinical judgment, guided by the principles of right care, right time, right place, and right cost. Responsibilities include peer-to-peer clinical discussions, denials management (appeals), and contributions to population health topics. The role supports the mission and vision of Priority Health and requires maintaining Board Certification in a Medical or Surgical specialty from a nationally recognized specialty board.

Responsibilities

• Understand Priority Health’s mission, strategic goals, and value proposition for our communities and the people we serve.
• Actively participate in support of medical management.
• Provide clinical oversight to nurse case management and utilization management.
• Promote and advocate for patient-centered care, evidence-based medicine, and lower per-capita costs.
• Participate in the development of clinical utilization guidelines, health management programs, and clinical quality programs.
• Promote evidence-based care standards with community physician partners.
• Engage in peer-to-peer clinical discussions and denials management, including review of previous clinical decisions (appeals).
• Contribute to discussions on population health topics.

Requirements

• Doctorate degree.
• 3+ years of relevant clinical experience in a healthcare setting.
• 3+ years of managed care experience.
• Proven experience in effective physician communication, education, and application of utilization management skills.
• Licensed as a Physician (MD) or Osteopathic Physician (DO) in the State of Michigan (required within 90 days of hire).
• Board Certification in a Medical or Surgical specialty from one of the following upon hire:
  • AOA (American Osteopathic Association)
  • AMBS (American Board of Medical Specialties)
  • AAHPM (American Academy of Hospice & Palliative Medicine)
  • ABFAS (American Board of Foot & Ankle Surgery)
  • ABOMS (American Board of Oral & Maxillofacial Surgery)
  • ABPM (American Board of Podiatric Medicine)
  • ABSM (American Board of Sleep Medicine)
  • ABAM (American Board of Addiction Medicine)
  • ASAM (American Society of Addiction Medicine)
• Working knowledge of national utilization management tools such as InterQual and Milliman (preferred).

Benefits

• Comprehensive benefits package to meet financial, health, and work/life balance goals.
• On-demand pay program powered by Payactiv.
• Discounts on restaurants, phone plans, spas, and more.
• Optional identity theft protection, home, and auto insurance.
• Traditional and Roth retirement options with service contribution and match savings.

Schedule

• Full-time position.
• Day shift: 8 a.m. to 5 p.m., Monday to Friday.
• Weekly scheduled hours: 40.
• Variable weekends as needed.

Primary location: Priority Health, 1231 E Beltline Ave NE, Grand Rapids, MI.