Medical Director Utilization Management, Clinical Specialty

About the role

At Quantum Health, the leader in healthcare navigation, we are privileged and humbled to serve an amazing group of clients and members. As our relationships flourish and our business expands, we find ourselves in the fortunate position of adding a Medical Director to our incredible team. This physician will possess relevant experience within the virtual healthcare space. This experience may be with a traditional/non-traditional carrier or another administrative healthcare service provider. In addition, they will possess the unique combination of strong analytical skills, collaboration, responsiveness, diligence and a passion for both written and verbal communications.

Essential Responsibilities

• Serves as a key clinical resource for staff. Establishes criteria and protocols for standard medical treatment inquiries and renders determinations on requests for healthcare services and/or treatment. Conducts daily review of individual cases and has necessary case level conversations as requested. This includes prior authorizations and denial decisions for cases that do not meet established evidence-based criteria.
• Provides clear and concise documented medical review determinations and support on requested reviews within the established time frames.
• Provides clinical and nurse consultations.
• Identifies opportunities to implement best practices approaches and introduce innovations to provide improved outcomes.
• Performs utilization review and case management support on complex members.
• Supports over the phone, through messaging and video to support chronic disease management.
• Offers peer-to-peer discussions regarding determinations as necessary.
• Serves as a medical liaison to physicians, hospitals and insurance carriers.
• Provides determination on appeals for cases where they did not make the initial determination.
• Utilizes data resources and tools that helps our team provide personalized care to our clients.
• Evaluates and interprets data. Identifies areas for improvement with a focus on interventions to improve client outcomes.
• All other duties as assigned.

Qualifications

• Education: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• Licenses/Certifications: Board certification in primary specialty required.
• Experience: Minimum of five (5) years of progressively responsible clinical practice experience. Minimum of two (2) years of physician clinical review experience, preferably within a commercial health plan or utilization management environment.
• Skills: Strong written and verbal communication skills, including clear clinical documentation. Collaborative, team-oriented mindset with the ability to work effectively across disciplines. Knowledge of the U.S. healthcare delivery system. Demonstrated knowledge of utilization management principles and evidence-based criteria (e.g., InterQual).
• Other: Commitment to protecting company and member data by adhering to organizational ethics, privacy, and security policies. Hold a current, valid, and unrestricted license to practice medicine that is recognized in the relevant jurisdiction(s); ability to obtain and maintain multistate licensure as required. Maintain licensure of a type and scope that permits the application of independent clinical judgment to evaluate member needs and render utilization review determinations. Be knowledgeable of the clinical issues under review, including applicable medical or behavioral health conditions, procedures, treatments, and services. Demonstrate familiarity with current, evidence-based clinical guidelines, standards of care, and relevant emerging or novel treatments. Be qualified to render clinical opinions and utilization review determinations, as determined by organizational leadership, and perform reviews within the scope of licensure and professional practice. Function under and provide oversight consistent with Medical Director responsibilities for utilization management activities. A high degree of personal accountability and trustworthiness, a commitment to working within Quantum Health’s policies, values and ethics, and to protecting the sensitive data entrusted to us.