Medical Director - National Medicare - Remote

Overview

The Medical Director relies on medical background and reviews health claims to make determinations on services and care levels in compliance with regulatory standards.

In Short

• Review health claims and clinical records.
• Make determinations on service authorization.
• Utilize national clinical guidelines and CMS policies.
• Engage in discussions with external physicians.
• Support regional market priorities.
• Conduct Utilization Management of care received by members.
• Collaborate with team members and other departments.
• Work independently with minimal direction.
• Participate in grievance and appeals reviews.
• May engage in project teams or organizational committees.

Requirements

• MD or DO degree with 5+ years of clinical experience.
• Current Board Certification in an approved ABMS Medical Specialty.
• Current and unrestricted medical license.
• Excellent verbal and written communication skills.
• Experience in quality management and utilization management.
• Knowledge of Medicare Advantage and Managed Medicaid.
• Experience with national guidelines such as MCG or InterQual.
• Advanced degree such as an MBA, MHA, or MPH is preferred.
• Familiarity with social determinants of health.
• Ability to adapt and innovate.

Benefits

• Competitive medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off including holidays and volunteer time.
• Short-term and long-term disability coverage.
• Life insurance and additional opportunities.