The Medical Director relies on medical background and reviews health claims. The Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.
The Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.
- 5+ years of clinical experience
- A current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of assignment
- MD or DO degree
- Board Certified in an approved ABMS Medical Specialty
- Excellent communication skills with 5 years of established clinical experience
- Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products
- Possess analysis and interpretation skills with prior experience leading teams focusing on quality management, utilization management, discharge planning and/or home health or rehab
- Medical management organizations, hospitals and experience, working with health insurance other healthcare providers, patient interaction, etc.
- Internal Medicine, Family Practice, Geriatrics, Hospitalist clinical specialists.
- Previous Medicare, Medicaid, and/or Commercial experience.
- The Medical Director conducts clinical reviews of the care received by members in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews and/or condition committees. Must hold a MD or DO and be board certified and typically reports to a Lead or Regional or Corporate Medical Director, depending on size of region/line of business. No direct supervisory responsibility is expected though it may occur or the Medical
Scheduled Weekly Hours