Senior Medical Director, Health Plan

About the Role

The Senior Medical Director serves as a key clinical executive within the health plan, providing strategic leadership, medical oversight, and clinical expertise to ensure high-quality, cost-effective care for members. This role partners closely with executive leadership, clinical operations, network management, quality, and compliance teams to shape clinical strategy, guide utilization management, and support value-based care initiatives. The Senior Medical Director represents the health plan externally with providers, regulators, and community partners. This position requires patient care.

Responsibilities

• Develop and execute clinical strategies that improve member outcomes, reduce unnecessary utilization, and support organizational goals.
• Provide medical expertise to guide benefit design, population health programs, and value-based care models.
• Serve as a clinical advisor to senior executives and cross-functional teams.
• Oversee utilization management (UM) programs, ensuring evidence-based, timely, and compliant decision-making.
• Review complex or escalated cases, appeals, and grievances, and ensure UM policies align with regulatory requirements, accreditation standards, and clinical best practices.
• Lead quality improvement initiatives, including HEDIS, Stars, NCQA, and other performance programs.
• Partner with analytics teams to identify trends in utilization, quality, and member health outcomes.
• Support the development of population health programs targeting chronic disease management, behavioral health, and social determinants of health.
• Collaborate with provider network teams to improve clinical performance, reduce variation, and support value-based contracting.
• Engage with physicians and health systems to promote evidence-based care and address performance issues.
• Represent the health plan in provider forums, committees, and external meetings.
• Ensure clinical programs comply with federal and state regulations, accreditation standards, and internal policies.
• Participate in audits, regulatory reviews, and accreditation activities.
• Maintain up-to-date knowledge of evolving healthcare regulations and clinical guidelines.
• Partner with behavioral health, pharmacy, care management, and social care teams to coordinate integrated care strategies.
• Provide medical leadership for product development, member engagement initiatives, and clinical innovation projects.
• Support executive leadership with clinical insights for strategic planning and organizational decision-making.

Requirements

• Doctorate in a related field of study (required).
• Physician state license (required).
• 8-10+ years of clinical experience.
• 5-7 years of experience in managed care, health plan, or population health leadership role.

Skills

• Strategic thinking and clinical judgment.
• Executive communication and influence.
• Data-driven decision-making.
• Collaborative leadership.
• Regulatory and compliance awareness.
• Provider engagement and relationship-building.

Pay

$320,000 - $350,000 (depending upon experience).

Schedule

• Scheduled weekly hours: 40.
• Work shift: Day (United States of America).
• Employee type: Regular.

Location

Remote work from 399 Revolution Drive.