Medical Director, Utilization Review

Medical Director

Curative is seeking an enthusiastic and highly skilled Medical Director to join our growing team. This pivotal role will be responsible for overseeing and performing utilization reviews, prior authorizations, and making crucial medical necessity determinations. The Medical Director will serve as a key clinical expert, ensuring appropriate resource utilization, promoting evidence-based care, and fostering positive relationships with practitioners through effective peer-to-peer discussions. This is a remote position requiring a "roll up your sleeves" attitude and a genuine excitement for the dynamic and collaborative environment of a startup.

Key Responsibilities:

• Perform comprehensive medical necessity reviews (prospective, concurrent, and retrospective) for a wide range of healthcare services, applying clinical expertise, established medical policies, and evidence-based guidelines.
• Conduct thorough prior authorization reviews, ensuring alignment with clinical criteria, regulatory requirements, and contractual agreements.
• Lead and conduct effective peer-to-peer discussions with requesting practitioners, providing clear clinical rationales for determinations, facilitating open dialogue, and seeking alternative solutions when appropriate.
• Issue medical necessity denials when warranted, providing comprehensive and well-documented rationales in compliance with all relevant regulations and appeal processes.
• Collaborate closely with internal teams, including Nurse Practitioners, Care Coordinators, and Operations, to optimize utilization management processes and improve member outcomes.
• Contribute to the development, review, and revision of medical policies, clinical guidelines, and utilization management protocols.
• Participate in quality improvement initiatives, audits, and committee meetings as required.
• Maintain meticulous documentation of all review activities, decisions, and peer-to-peer interactions.
• Stay abreast of current medical literature, healthcare trends, regulatory changes, and industry best practices in utilization management.
• Champion a member-centric approach while balancing clinical efficacy and cost-effectiveness.
• Embrace the fast-paced, evolving nature of a startup environment, demonstrating adaptability and a proactive approach to problem-solving.

Qualifications:

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school.
• Board Certification in a medical specialty.
• Active and unrestricted Medical License in at least one US state, with the ability to obtain additional state licenses as needed (Curative will support additional licensure processes).
• Minimum of 5 years of clinical practice experience.
• Minimum of 2-3 years of experience in utilization management, medical review, or prior authorizations within an insurance or managed care organization.
• Demonstrated success in conducting peer-to-peer discussions with external practitioners, with excellent communication and interpersonal skills.
• Profound understanding of medical necessity criteria, evidence-based medicine, and healthcare utilization management principles.
• Strong analytical and critical thinking skills, with the ability to synthesize complex clinical information and make sound medical decisions.
• Exceptional written and verbal communication skills, capable of explaining complex medical decisions clearly and empathetically.
• Proficiency with electronic health records (EHR) systems and utilization management software.
• Self-motivated, highly organized, and able to manage a high volume of cases effectively in a remote work environment.
• A "roll up your sleeves" attitude and a genuine excitement for contributing to a rapidly growing, innovative startup.
• No travel required for this position.

Perks & Benefits:

• Curative Health Plan (100% employer-covered medical premiums for you and 50% coverage for dependents on the base plan.)
• $0 copays and $0 deductibles (with completion of our Baseline Visit)
• Preventive and primary care built in
• Mental health support (Rula, Televero, Two Chairs, Recovery Unplugged)
• One-on-one care navigation
• Chronic condition programs (diabetes, weight, hypertension)
• Maternity and family planning support
• 24/7/365 Curative Telehealth
• Pharmacy benefits
• Comprehensive dental and vision coverage
• Employer-provided life and disability coverage with additional supplemental options
• Flexible spending accounts
• Flexible work options: remote and in-person opportunities
• Generous PTO policy plus 11 paid annual company holidays
• 401K for full-time employees
• Generous Up to 812 weeks paid parental leave, based on role eligibility.