Senior Medical Director

Job Description

Job Description

Shape clinical decision-making across 225,000+ covered lives. Join a 4.5-star Medicare Advantage plan at a pivotal moment of growth—one hour from Pittsburgh, with the quality of lfe only a tight-knit community can offer. Established in 1979, The Health Plan is a West Virginia-based, not-for-profit health maintenance organization headquartered in Wheeling, with additional offices in Charleston, Morgantown, and Massillon, OH. THP is clinically driven, technology-enhanced, and customer-focused—delivering comprehensive managed care products and services across commercial, Medicare Advantage, Medicaid, and self-funded lines of business.

Based in Wheeling, WV—one hour from Pittsburgh—and reporting to the Chief Medical Officer, the Sr. Medical Director will lead clinical programs that directly shape the quality, cost-effectiveness, and member experience of care across all THP product lines.

This is a hands-on physician leadership role that blends daily clinical decision-making with strategic program development. The Sr. Medical Director will serve as a trusted clinical voice across the organization, working closely with the CMO and having a direct line of influence on utilization management, quality improvement, and provider engagement.

Impact You'll Make

Clinical & Utilization Leadership

1. Direct clinical oversight of utilization management across 225,000+ members, establishing best-practice standards and clinical pathways.
2. Review and authorize or deny care based on medical appropriateness, maintaining daily interaction with hospital review, case managers, pharmacy managers, and clinical staff.
3. Serve as the physician voice in appeal and grievance processes, available for telephonic practitioner consultation and 24-hour case review coverage as needed.

Quality & Outcomes

1. Lead development and implementation of the Quality Management Program, including annual work plans, program evaluations, and continuous improvement initiatives.
2. Chair or participate in key committees: Quality Improvement, Credentials, Pharmacy & Therapeutics, Transplant & Technology, and Utilization Management.
3. Monitor clinical quality issues, analyze data for barriers and corrective actions, and drive measurable improvement in HEDIS scores and Star Ratings.

Provider Engagement & Education

1. Partner with Network Development to build effective provider education programs that drive acceptance of clinical guidelines and appropriateness criteria.
2. Work directly with physician groups to foster collaboration, build trust, and advance shared quality and cost goals.

Strategic Contribution

1. Participate in developing clinical practice guidelines and selecting proprietary criteria and clinical pathways that raise the standard of care.
2. Serve as a valued, authoritative voice on evidence-based medicine, advising executive leadership on integrating medical advances into organizational strategy.
3. Help shape THP's clinical direction across commercial, Medicare Advantage, Medicaid, and self-funded business lines.

We are looking for a physician executive who brings not just credentials but conviction—someone who is energized by the work of improving healthcare delivery at a community-rooted health plan and who sees this role as a platform for meaningful impact and career growth.

Required Qualifications

1. MD or DO with current board certification
2. Active, non-restrictive medical license
3. Minimum five years of post-graduate clinical experience preferred
4. Ideally, a minimum of three years of managed care experience

What Will Set You Apart

1. Experience across multiple business lines—Commercial, Individual, Medicare Advantage, and ASO
2. Deep knowledge of healthcare delivery systems, strategic intervention strategies, care planning, and transition models
3. Fluency in regulatory requirements, including NCQA, CMS, and state regulations
4. Strong analytical capabilities and comfort with data-driven decision-making
5. A track record of building trust, fostering collaboration, and driving operational excellence
6. Exceptional communication skills—the ability to translate complex clinical concepts for diverse audiences
7. A patient-centered philosophy that balances quality outcomes with affordability