Medical Director

Job Description

JOB SUMMARY :

The Medical Director will exhibit strong expertise in utilization management and health plan leadership for our provider sponsored organization. They will have a proven track record working within a health plan environment, with a deep understanding of clinical operations, healthcare utilization, and strategies for controlling healthcare costs while maintaining high-quality care. This key role within our Clinical Operations team is pivotal in optimizing the efficiency and effectiveness of our health plan’s utilization management programs, ensuring that medical services are delivered in a cost-effective manner while meeting the clinical needs of our members.

KEY RESPONSIBILITIES :

• Lead and oversee the health plan's utilization management policies, ensuring that care is appropriately managed across all settings (inpatient, outpatient, ancillary services, etc.). Establish and enforce medical necessity criteria, review processes, and decision-making protocols. Collaborate with providers to enhance care coordination and cost efficiency through peer-to-peer reviews and secondary reviews.
• Develop and implement cost-effective strategies for managing the utilization of healthcare services. Utilize data-driven approaches to identify trends and opportunities to improve care delivery while reducing unnecessary costs. Collaborate with other departments to integrate cost containment initiatives across the plan.
• Provide clinical oversight and direction for the medical management team. Serve as a subject matter expert on clinical best practices, evidence-based guidelines, and cost-effective care delivery. Management of and / or participation in internal company committees as requested.
• If not involved with the initial denial determination, renders an appeal determination on medical, behavioral or drug utilization management cases under review.
• Work closely with cross-functional teams including the network management, claims, quality improvement, and pharmacy departments to design, implement, and monitor health plan initiatives.
• Ensure compliance with all relevant federal and state regulations, accreditation standards, and health plan policies. Stay current with industry trends, regulatory changes, and emerging healthcare technologies related to utilization management and cost control.
• Develop and track performance metrics related to utilization, cost control, and quality outcomes. Provide regular reports to senior leadership, identifying opportunities for improvement and recommending actionable steps.
• Educate and support providers on evidence-based guidelines and efficient care delivery practices. Engage with members to promote care management and prevention programs that align with cost-effective health outcomes.
• Promote a culture of continuous improvement within the medical management team. Lead efforts to enhance the efficiency of clinical workflows, reduce administrative burden, and introduce innovative solutions to optimize both clinical care and cost-effectiveness.
• Perform other duties as assigned.

QUALIFICATIONS :

EDUCATION / EXPERIENCE :