Medical Director

Medical Director - Utilization Management

Location: Remote
Reports to: Senior Medical Director or Clinical Operations Leadership
Employment Type: Full-Time

Position Summary

The Medical Director is responsible for the administration of physical and/or behavioral health medical services to ensure members receive appropriate, high-quality, and cost-effective care. This role provides clinical and strategic leadership across utilization management, appeals, quality, and clinical operations, and may oversee an entire clinical program.

The Medical Director serves as a clinical advisor and subject-matter expert, supporting clinicians, providers, internal stakeholders, and Medical Director Associates to improve quality, outcomes, operational effectiveness, and cost of care.

Key Responsibilities

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  Administer physical and/or behavioral health medical services to ensure appropriate and cost-effective care.
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  Conduct peer-to-peer clinical reviews with attending physicians, ordering providers, and other treating clinicians to discuss utilization review determinations.
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  Conduct peer-to-peer clinical appeal reviews with providers to discuss appeal determinations and clinical rationale.
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  Support clinicians to ensure timely, consistent, and clinically appropriate responses to members and providers.
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  Provide guidance on the clinical operational aspects of assigned programs.
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  Interpret medical policies, clinical guidelines, and regulatory requirements to support consistent review decisions.
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  Develop, propose, and update medical policies based on changes in clinical practice, healthcare standards, and regulatory requirements.
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  Identify and develop cost-of-care opportunities while maintaining quality of care and positive member outcomes.
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  Lead, develop, direct, and implement clinical and non-clinical activities that impact healthcare quality, cost, and outcomes.
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  Develop and implement programs designed to improve quality, cost, and clinical outcomes.
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  Identify opportunities for innovation to increase clinical and operational effectiveness.
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  Serve as a clinical resource and consultant to internal departments, including Medical Director Associates and clinical operations teams.
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  May provide oversight, direction, and guidance to Medical Director Associates.
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  May be responsible for the management of an entire clinical program, including program development, implementation, and ongoing oversight.
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  Represent the organization with external entities, providers, regulators, and other stakeholders as needed.
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  Serve on and may chair internal or external committees.
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  Conduct patient office visits with providers and external physicians when applicable.

Qualifications

Required

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  MD or DO degree from an accredited medical school.
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  Active, unrestricted medical license to practice medicine.
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  Board certification approved by the American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA), where applicable to the duties performed.
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  Minimum of 10 years of clinical experience, or an equivalent combination of education and experience.
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  Must be located in a U.S. state or territory when conducting utilization review or appeals considerations, unless expressly permitted by state or federal law or regulation.
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  May not be located on a U.S. military base, vessel, or embassy when performing utilization review or appeals activities.

Preferred

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  Experience in utilization management, utilization review, case management, clinical appeals, managed care, or health plan operations.
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  Experience in physical health, behavioral health, or both.
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  Experience leading clinical programs, clinical policy development, or clinical operations teams.
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  Experience providing clinical consultation and peer-to-peer education.
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  Knowledge of CMS, NCQA, state regulatory requirements, and evidence-based clinical guidelines.
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  Strong communication, collaboration, and clinical leadership skills.

Medical, dental, and vision insurance are available to qualified candidates who meet eligibility requirements.