Responsibilities:

The Medical Director will apply clinical expertise; experience as a practicing physician and utilization management experience to promote the appropriate delivery of medically necessary services to the populations served in multiple states. She/he will perform reviews for appeals, grievances, complaints and disputes, ensuring compliance with medical policy and compliance with all federal, state and local regulatory guidelines. The Medical Director serves as a physician liaison working closely with other medical management team members; assists in the development and implementation of medical policy, including recommendations for modifications to enhance efficiency and effectiveness; and assists in the identification and analysis of medical information to develop interventions to improve quality of care and outcomes and ensure proper provision for participants.

Education/Experience:

• Medical Degree (M.D. or D.O.)
• Active board certification in Family Medicine preferred.
• 2+ years full-time experience practicing medicine.
• 3+ years of prior experience as a Utilization Management Associate Medical Director (or equivalent) or physician reviewer in a Managed Care Plan preferred.
• The successful candidate will have multi-state licensure as well as Appeals experience.
• Long Term Services & Support (LTSS) experience preferred.
• Must be licensed to practice in the state(s) assigned as a medical director/doctor and recognized by the proper licensing authority. Active PA license required.
• Must be clear of any sanctions by the applicable state or Office of the Inspector General.
• Must not be prohibited from participating in any federally or State funded healthcare programs.