Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit
Provide medical leadership for utilization management, cost containment, and medical quality improvement activities
Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services
Support effective implementation of performance improvement initiatives for capitated providers
Collaborate with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals
Participate in provider network development and new market expansion as appropriate
Assist in the development and implementation of physician education with respect to clinical issues and policies
Identify utilization review studies and evaluate adverse trends in utilization of medical services
Develop alliances with the provider community through the development and implementation of the medical management programs

Medical Doctor or Doctor of Osteopathy
Utilization Management experience and knowledge of quality accreditation standards preferred
Actively practices medicine
Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous
Experience treating or managing care for a culturally diverse population preferred
Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services
Active American Board Certification in Internal or Family Medicine, preferred
Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

National Medical Director

Key skills