Medical Director-Health Plan
Job ID #1953923
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About this Role
Responsible for the appropriateness and quality of care delivered and for cost-effective utilization of services.
Job details
$150.00 / hour
Remote, National
Profession: Medical Director
Facility Type: ???
Specialty: Health Plan
Division:
MedFi
Start Date: 10/27/2025
Responsibilities
Performs treatment authorization review to determine medical necessity, appropriateness of services, and interpret benefits and limitations. Reviews that care is consistent with the Plan’s standards of quality.
Participates in concurrent review activities of inpatient and long term care plans.
Reviews claims that are unusual in cost, volume or scope of services.
Coordinates with Directors of Medical Management and Quality Improvement to provide daily support
Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for the appropriate use of services clinical practice guidelines, and treatment guidelines.
Reviews Potential Quality Issues and determines their appropriateness for review by the Peer Review Committee.
Performs Pharmacy Prior Authorization review in support of the Pharmacy Director
Participates in the Grievance and Appeal process as required, including performing second-level reviews of previous denials.
Participates in and leads special projects and assignments as requested.
Required Qualifications
MCG
Inpatient expertise
Excellent documentation skills
If a candidate is currently employed with a health plan it may create limitation on the authorization that this candidate can cover.
Board Certified in a recognized medical practice specialty.
Five years of post-residency experience in a recognized medical specialty – they are looking for candidates with inpatient experience
One year utilization management experience for an Independent Practice Association, medical group or HMO.
Knowledge and experience with MediCal and Medicare.
Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and PowerPoint.