Sr Medical Director

Key Responsibilities

• Provide clinical leadership for utilization management programs, including prior authorization, concurrent review, retrospective review, and appeals.
• Serve as senior clinical advisor to executive leadership on utilization trends, risk areas, and intervention opportunities.
• Oversee the medical policy team, development and refinement of utilization management policies, protocols, and criteria based on nationally recognized standards (e.g., MCG, InterQual).
• Lead the Medical Policy and Utilization Management Governance Committees
• Medical Decision-Making & Oversight
• Oversee complex and high-risk utilization review cases, including medical necessity determinations and claim reviews.
• Conduct clinical reviews and/or oversee peer-to-peer reviews with ordering and attending providers.
• Ensure consistent, evidence-based application of clinical guidelines and medical policy across all UM functions.
• Provide clinical expertise to teams conducting coding, payment integrity, and reimbursement activities.
• Contribute medical expertise to case management and care coordination processes, ensuring members transition to the appropriate level of care.
• Provider & Stakeholder Engagement
• Act as senior clinical UM liaison to network providers, facilities, and delegated UM partners.
• Build and maintain strong physician relationships to support appropriate utilization, practice transformation, and quality improvement.
• Represent Medical Management in cross-functional leadership forums (Quality, Network, Pharmacy, Population Health).
• Program Performance & Improvement
• Lead development and implementation of UM interventions that reduce unnecessary utilization while maintaining or improving quality outcomes, including strategies for integration of AI technologies to improve efficiency, accuracy of reviews, and user experience.
• Review utilization data, denial patterns, appeals outcomes, and inter-rater reliability results to identify improvement opportunities and develop solutions for implementation and continuous quality improvement.
• Ensure UM programs meet CMS, URAC, and state regulatory requirements.
• Support workforce development, consistency of decision-making, and clinical calibration across UM teams.
• Conduct and support training of medical directors and UM staff.

Required Qualifications

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• Board Certified by an American Board of Medical Specialties (ABMS) board.
• Preferably, current, unrestricted medical license in Nebraska. If not currently actively licensed in Nebraska, verification of attainment within 6 months of start.
• 10+ years of combined clinical practice and health care industry experience.
• Demonstrated experience in utilization management, medical necessity review, and physician peer review.
• Demonstrated effective communication skills, a commitment to continuous improvement in healthcare delivery, and the ability to adapt to a dynamic and rapidly evolving healthcare environment.

Preferred Qualifications

• Prior experience in a senior or enterprise-level UM leadership role.
• Three + years Managed care experience across Commercial and/or Medicare Advantage populations.
• Experience leading or overseeing other Medical Directors.
• Strong background in quality improvement, population health, and cost containment initiatives.