Senior Medical Director
Jobleads-US
Responsibilities
- Provide clinical leadership for utilization management programs
- Set UM strategy aligned with organizational goals
- Serve as senior clinical advisor to executive leadership on utilization trends
- Oversee the medical policy team
- Lead the Medical Policy and Utilization Management Governance Committees
- Oversee complex and high-risk utilization review cases
- Conduct clinical reviews and peer-to-peer reviews
- Ensure consistent, evidence-based application of clinical guidelines
- Provide clinical expertise to teams conducting coding and payment integrity
- Act as senior clinical UM liaison to network providers
- Build and maintain strong physician relationships
- Lead development and implementation of UM interventions
- Review utilization data for improvement opportunities
- Ensure UM programs meet regulatory requirements
- Conduct and support training of medical directors and UM staff
Requirements
- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO)
- Board Certified by an American Board of Medical Specialties (ABMS) board
- Preferred current, unrestricted medical license in Nebraska
- 10+ years of combined clinical practice and health care industry experience
- Demonstrated experience in utilization management, medical necessity review, and physician peer review
- Demonstrated effective communication skills
- Prior experience in a senior or enterprise-level UM leadership role
- Three + years Managed care experience across Commercial and/or Medicare Advantage populations
- Strong background in quality improvement, population health, and cost containment initiatives
Hard Skills
- utilization management
- medical necessity review
- peer review
- clinical reviews
- evidence-based clinical guidelines
- coding integrity
- payment integrity
- quality improvement
- population health
- cost containment
Soft Skills
- clinical leadership
- effective communication
- relationship building
- strategic planning
- team leadership
- training and development
- analytical skills
- problem-solving
- collaboration
- advisory skills
Certifications & Qualifications
- Doctor of Medicine (MD)
- Doctor of Osteopathic Medicine (DO)
- Board Certified by ABMS
- unrestricted medical license
Vacancy posted 2 days ago
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