Supervisory Medical Director – National Physical Health Appeals, Outpatient UM

Role Overview

• Provides medical and leadership expertise to ensure high-quality, cost-effective care for our members.
• Assists the Senior Medical Director and Chief Medical Officer in execution of operational and strategic clinical initiatives.
• Provides operational leadership, coaching and mentorship for a team of front-line medical directors.
• Participates in creation and updates to new hire and existing medical director training.
• Supports Chief Medical Officer and Sr. Medical Director in the execution of strategic clinical initiatives.
• Participates in utilization review studies, performance management and trend analysis.
• Handles complex and high-profile utilization management cases, ensuring timely and appropriate decision-making.
• Conducts and participates in case escalation reviews, collaborating with healthcare providers and market leadership to resolve disputes and or complaints.
• Oversees and actively participates in the appeals process, ensuring that appeals are handled efficiently, thoroughly, and in compliance with regulatory requirements.
• Provides clinical guidance and training to appeals medical director team around regulatory updates.
• Collaborates closely with clinical teams, UM teams, and network providers to ensure understanding and adherence to utilization management clinical coverage criteria.

Requirements

• Medical Doctor (MD) Graduate of an accredited medical school required
• Master's Degree MBA, MPH, or epidemiologist degree preferred
• 5+ years Managed care/ clinical experience; experienced with commercial, Medicare and Medicaid lines of business required
• 1+ years Supervisory/management experience preferred
• Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services required
• American Board Certification in Internal or Family Medicine, preferred.
• MD
• Physician
• State Licensure Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs required

Benefits

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• flexible approach to work with remote, hybrid, field or office work schedules