About this role

Provide clinical leadership and expertise to Medical Management staff, ensuring timely, consistent, and evidence-based responses to members and providers.
Lead utilization management and quality assurance activities, including oversight of medical necessity reviews and case management initiatives.
Support medical management programs through active participation in interdisciplinary clinical team activities and strategic decision-making.
Serve as the primary clinical and business liaison to network providers and healthcare facilities, fostering collaboration and supporting the effective implementation of medical services programs.
Conduct predetermination reviews and claim determination reviews, applying clinical judgment and expertise in medical coding, reimbursement, and coverage policies.
Provide guidance and consultation on complex clinical cases, helping ensure quality outcomes and regulatory compliance.
Support the development and continuous improvement of medical management strategies, policies, and processes.

2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry
Active and current state medical license without encumbrances
M.D. or D.O., Board Certification in Pain Management specialty including post-graduate direct patient care experience specifically

Medical Director – Pain Management

Key skills