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Role Description

The Medical Director will have program management responsibilities including:

• Clinical policy development
• Program development/implementation
• Overseeing clinical/non-clinical activities
• Utilization review/management

May also be responsible for:

• Developing and implementing programs to improve quality, cost, and outcomes
• Providing clinical consultation and serving as clinical/strategic advisor to enhance clinical operations
• Identifying cost of care opportunities
• Serving as a resource to staff including Medical Director Associates
• Managing an entire clinical program

How you will make an impact:

• Supports clinicians to ensure timely and consistent responses to members and providers
• Provides guidance for clinical operational aspects of a program
• Conducts peer-to-peer clinical reviews with attending physicians or other providers
• May conduct peer-to-peer clinical appeal case reviews
• Serves as a resource and consultant to other areas of the company
• May represent the company to external entities and/or serve on internal and/or external committees
• May chair company committees
• Interprets medical policies and clinical guidelines
• May develop and propose new medical policies based on changes in healthcare
• Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes
• Identifies and develops opportunities for innovation to increase effectiveness and quality

Qualifications

• Requires MD or DO and Board certification approved by ABMS or AOA
• Must possess an active unrestricted medical license to practice medicine or a health profession
• Minimum of 10 years of clinical experience; or any combination of education and experience providing an equivalent background
• For Health Solutions and Carelon organizations, minimum of 5 years of experience providing health care is required
• Strong oral, written, and interpersonal communication skills
• Problem-solving skills, facilitation skills, and analytical skills

Requirements

• Must be located in a state or territory of the United States when conducting utilization review or appeals consideration
• Associates in this role must follow specific policies, procedures, guidelines as stated by the Government Business Division

Preferred Qualifications

• Experience in managed care strongly preferred
• 1-2 years utilization management review experience preferred
• Clinical experience working in internal medicine or family practice strongly preferred
• Knowledgeable of Medicaid/Medicare policies and guidelines strongly preferred

Benefits

• Market-competitive total rewards including merit increases, paid holidays, Paid Time Off, and incentive bonus programs
• Medical, dental, vision, short and long term disability benefits
• 401(k) + match, stock purchase plan, life insurance
• Wellness programs and financial education resources