Medical Director-Health Plan
Job ID #1919362
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About this Role
Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
Job details
$141.08 / hour
Remote, National
Profession: Medical Director
Facility Type: ???
Specialty: Health Plan
Division:
MedFi
Start Date: 09/17/2025
Responsibilities
Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.
Supports effective implementation of performance improvement initiatives for capitated providers.
Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
Participates in provider network development and new market expansion as appropriate.
Assists in the development and implementation of physician education with respect to clinical issues and policies.
Required Qualifications
1+ years UM experience - Medicare UM experience. Proven ability to handle high-volume case reviews efficiently and accurately.
Medical Doctor or Doctor of Osteopathy
Extensive state licensing highly preferred
Clinical Expertise: Board-certified physician with active practice experience. Needs at least 3+ years of in clinic office experience.
Behavioral Health Experience: For Behavioral Health only - Board certification by the American Board of Psychiatry and Neurology.
Current state medical license without restrictions.
Tech Savvy: Comfortable using EMR systems and collaborating virtually.
Adaptability: Can work independently in a remote setting while engaging with a dynamic team.
Regulatory Knowledge: Familiarity with accreditation standards and state-specific requirements.