Medical Doctor/Physician

Position Title: Medical Director
Work Location: Remote – Nationally Sourced
Assignment Duration: 6 months with potential to extend or convert
Work Schedule: 8 am – 5 pm in candidate’s time zone (EST, CST, PST)

Position Summary:
• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.

Key Responsibilities:
• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.
• Supports effective implementation of performance improvement initiatives for capitated providers.
• Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
• Participates in provider network development and new market expansion as appropriate.
• Assists in the development and implementation of physician education with respect to clinical issues and policies.
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
• Develops alliances with the provider community through the development and implementation of the medical management programs.
• As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.
• Represents the business unit at appropriate state committees and other ad hoc committees.
• May be required to work weekends and holidays in support of business operations, as needed.
• Performs other duties as assigned
• Complies with all policies and standards

Qualification & Experience:
• Medical Doctor or Doctor of Osteopathy
• Utilization Management experience
• Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services (Psychiatry if Behavioral Health)
• Current state medical license without restrictions
• Course work in Health Admin, Financing, Insurance preferred
• Experience treating or managing care for culturally diverse population preferred

Candidate Requirements Education/Certification Required: Medical Doctor or Doctor of Osteopathy.
Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services. Preferred: Licensure Required: need to be licensed Preferred:

• Years of experience required
• Disqualifiers
• Best vs. average
• Performance indicators

Must haves:
UM experience (minimum of 1 year experience)
Nice to haves:
Medicare UM experience
Extensive state licensing
Disqualifiers:
Not meeting the board certification
Performance indicators:
Production capacity around the 45 cases per day
Quality of the review

A strong candidate would meet the following:

1. Clinical Expertise : Board-certified physician with active practice experience.
2. UM Proficiency : Proven ability to handle high-volume case reviews efficiently and accurately.
3. Behavioral Health Experience : Especially valuable if applying for roles requiring psychiatry certification.
4. Tech Savvy : Comfortable using EMR systems and collaborating virtually.
5. Adaptability : Can work independently in a remote setting while engaging with a dynamic team.
6. Regulatory Knowledge : Familiarity with accreditation standards and state-specific requirements.