Medical Director National OP, Medicare

Accountabilities:

Review preauthorization requests and complex clinical documentation to determine the medical necessity and appropriateness of requested services, treatments, levels of care, and service settings.
Apply medical expertise, clinical judgment, national clinical guidelines, Medicare and Medicare Advantage requirements, applicable CMS policies, internal clinical policies, and contractual obligations to make consistent, evidence-based determinations.
Conduct computer-based reviews of clinical scenarios, including cases arising primarily from inpatient and post-acute care settings, evaluating submitted medical records and relevant clinical information.
Prioritize daily case reviews, manage assigned workloads effectively, and ensure that utilization management decisions meet established regulatory and departmental deadlines.
Communicate clinical determinations clearly and accurately through written documentation, ensuring consistency in clinical reasoning and compliance with applicable standards.
Engage in regular telephone discussions with external physicians to obtain additional clinical information, clarify treatment plans, explain determinations, and resolve disagreements professionally when necessary.
Collaborate with internal clinical teams, colleagues across departments, regional healthcare leaders, and other stakeholders to support appropriate care delivery and operational objectives.
Develop and apply knowledge of Medicare and Medicare Advantage regulations, policies, and operational requirements to ensure compliant and effective clinical decision-making.
Participate in grievance and appeals reviews when required, providing objective medical interpretation and supporting fair, evidence-based evaluations of disputed decisions.
Contribute to care management activities and collaborate with case managers and care managers on complex cases, as applicable to the assigned responsibilities.
Support organizational projects, clinical initiatives, and departmental committees that advance care quality, utilization management effectiveness, and population health objectives.
Build collaborative relationships with contracted physicians, medical groups, healthcare facilities, and community organizations to support regional priorities and improve care coordination.
Contribute to initiatives involving value-based care, disease management, population health, clinical documentation, and healthcare performance measurement, as relevant to the role.
Work independently following structured onboarding and mentored training, exercising sound judgment while adhering to established procedures, clinical standards, and departmental expectations.
Requirements:
Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree.
At least five years of direct clinical patient care experience following residency or fellowship, preferably including inpatient care and/or experience treating Medicare populations, including adults aged 65 and older or individuals with disabilities.
Current and ongoing board certification in an approved specialty recognized by the American Board of Medical Specialties (ABMS).
A current, unrestricted medical license in at least one U.S. jurisdiction, with willingness to obtain additional state licenses if required.
No current sanctions from federal or state government organizations and the ability to successfully complete all applicable credentialing requirements.
Strong clinical assessment and analytical skills, including the ability to interpret complex medical records, evaluate competing clinical considerations, and make well-supported determinations.
Excellent written and verbal communication skills, with the ability to document clinical reasoning clearly and discuss medical decisions effectively with physicians and other healthcare professionals.
Demonstrated ability to exercise independent medical judgment while maintaining consistency, objectivity, and compliance with established clinical and regulatory standards.
Strong interpersonal and conflict-resolution skills, particularly when discussing clinical determinations with external providers or addressing differing medical opinions.
Adaptability, intellectual curiosity, and a willingness to learn evolving regulations, clinical guidelines, operational processes, and healthcare technologies.
Ability to manage multiple priorities, meet time-sensitive review requirements, and work effectively in a structured, remote environment.
Familiarity with utilization management responsibilities, including evaluating medical necessity, appropriate levels of care, and service authorization requirements.
Preferred qualifications:
Knowledge of managed care, Medicare Advantage, and/or Managed Medicaid programs.
Previous utilization management experience within a medical management review organization, Medicare Advantage plan, managed Medicaid program, or commercial health insurance environment.
Experience applying established clinical decision-support guidelines, such as MCG or InterQual.
An advanced degree, such as a Master of Business Administration (MBA), Master of Health Administration (MHA), or Master of Public Health (MPH).
Exposure to public health, population health management, healthcare analytics, and the use of business metrics to evaluate clinical and operational performance.
Experience collaborating with case managers or care managers on complex care management cases, including familiarity with social determinants of health.
Interest in continuous learning, innovative approaches to healthcare delivery, and opportunities to improve clinical quality and operational effectiveness.
Benefits:
Competitive annual salary: $223,800–$313,100, depending on geographic location, qualifications, experience, education, and other job-related factors.
Performance-based compensation: Eligibility for a bonus incentive plan based on individual and/or organizational performance.
Comprehensive healthcare coverage: Medical, dental, and vision insurance options.
Retirement savings: Access to a 401(k) retirement savings plan.
Paid time off: Paid time off, company holidays, and personal holidays.
Family support: Paid parental leave and caregiver leave.
Financial protection: Short-term disability, long-term disability, and life insurance benefits.
Remote work flexibility: Work remotely from within the contiguous United States, with occasional travel to company offices for training or meetings as needed.
Work-life balance: A typical Monday-to-Friday schedule, generally from 8:00 a.m. to 5:00 p.m., with some flexibility based on business needs.
Professional development: Opportunities to expand expertise in Medicare regulations, utilization management, population health, and value-based healthcare.
Meaningful clinical impact: The opportunity to apply medical expertise beyond traditional clinical practice and help support appropriate, high-quality care for Medicare populations.
Collaborative environment: Work with experienced physicians, clinical professionals, and healthcare leaders on complex medical reviews and care improvement initiatives.