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

• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Administer physical and/or behavioral health medical services to ensure appropriate and cost-effective care.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Conduct peer-to-peer clinical reviews with attending physicians, ordering providers, and other treating clinicians to discuss utilization review determinations.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Conduct peer-to-peer clinical appeal reviews with providers to discuss appeal determinations and clinical rationale.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Support clinicians to ensure timely, consistent, and clinically appropriate responses to members and providers.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Provide guidance on the clinical operational aspects of assigned programs.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Interpret medical policies, clinical guidelines, and regulatory requirements to support consistent review decisions.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Develop, propose, and update medical policies based on changes in clinical practice, healthcare standards, and regulatory requirements.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Identify and develop cost-of-care opportunities while maintaining quality of care and positive member outcomes.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Lead, develop, direct, and implement clinical and non-clinical activities that impact healthcare quality, cost, and outcomes.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Develop and implement programs designed to improve quality, cost, and clinical outcomes.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Identify opportunities for innovation to increase clinical and operational effectiveness.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Serve as a clinical resource and consultant to internal departments, including Medical Director Associates and clinical operations teams.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> May provide oversight, direction, and guidance to Medical Director Associates.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> May be responsible for the management of an entire clinical program, including program development, implementation, and ongoing oversight.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Represent the organization with external entities, providers, regulators, and other stakeholders as needed.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Serve on and may chair internal or external committees.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Conduct patient office visits with providers and external physicians when applicable.

Qualifications Required

• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> MD or DO degree from an accredited medical school.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Active, unrestricted medical license to practice medicine.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Board certification approved by the American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA), where applicable to the duties performed.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Minimum of 10 years of clinical experience, or an equivalent combination of education and experience.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> 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.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> May not be located on a U.S. military base, vessel, or embassy when performing utilization review or appeals activities.

Preferred

• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Experience in utilization management, utilization review, case management, clinical appeals, managed care, or health plan operations.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Experience in physical health, behavioral health, or both.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Experience leading clinical programs, clinical policy development, or clinical operations teams.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Experience providing clinical consultation and peer-to-peer education.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Knowledge of CMS, NCQA, state regulatory requirements, and evidence-based clinical guidelines.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0"> Strong communication, collaboration, and clinical leadership skills.

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

By providing your phone number, you consent to: (1) receive automated text messages and calls from the Judge Group, Inc. and its affiliates (collectively "Judge") to such phone number regarding job opportunities, your job application, and for other related purposes. Message & data rates apply and message frequency may vary. Consistent with Judge's Privacy Policy, information obtained from your consent will not be shared with third parties for marketing/promotional purposes. Reply STOP to opt out of receiving telephone calls and text messages from Judge and HELP for help.