Medical Director - Medicaid

Accountabilities:: Conduct utilization management reviews for members within an assigned market, population, or clinical condition, evaluating whether requested or delivered services meet medical necessity and appropriateness criteria. Provide medical interpretations and determinations regarding healthcare services, levels of care, and treatment settings based on clinical evidence, national guidelines, CMS requirements, internal medical policies, and applicable contractual obligations. Review complex clinical cases, including inpatient and post-acute care scenarios, by thoroughly evaluating submitted medical records and supporting documentation. Apply clinical judgment and relevant regulatory knowledge to ensure consistent, accurate, and timely medical decisions while meeting established compliance requirements. Communicate determinations clearly to internal stakeholders and engage in regular discussions with external physicians to obtain additional clinical information, explain decisions, and resolve disagreements when necessary. Identify opportunities to improve care quality, utilization practices, discharge planning, and coordination across inpatient, outpatient, rehabilitation, and post-acute care settings. Collaborate with case managers, care managers, clinical teams, and other healthcare professionals on complex cases, supporting appropriate care transitions and effective care management strategies. Participate in grievance and appeals reviews, evaluating clinical information and ensuring decisions are supported by appropriate medical evidence and established guidelines. Work closely with regional leadership, departmental colleagues, and cross-functional teams to support market-wide healthcare priorities and organizational objectives. Contribute to projects, organizational committees, and quality improvement initiatives related to utilization management, population health, value-based care, and disease management. Build and maintain collaborative relationships with external physicians, healthcare facilities, provider groups, and community organizations to support regional healthcare initiatives. Support continuous improvement in clinical operations while promoting patient-centered care, regulatory compliance, and responsible healthcare resource utilization. Requirements: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree. At least 5 years of direct clinical patient care experience following residency or fellowship, preferably including inpatient care and/or experience serving Medicaid populations. Current and ongoing board certification in an approved medical specialty recognized by the American Board of Medical Specialties (ABMS). Active Louisiana and Oklahoma medical licenses, or the ability to obtain additional unrestricted medical licenses as required. No current sanctions from federal or state governmental organizations and the ability to successfully meet all applicable credentialing requirements. Excellent written and verbal communication skills, with the ability to explain complex clinical decisions, negotiate with healthcare professionals, and manage disagreements constructively. Strong analytical, critical-thinking, and clinical interpretation skills, particularly when reviewing complex medical records and determining medical necessity. Previous experience or exposure to quality management, utilization management, case management, discharge planning, home health, inpatient rehabilitation, or other post-acute care services. Ability to work independently, prioritize multiple clinical reviews, meet strict deadlines, and make consistent, evidence-based decisions with minimal supervision after completing initial training. Strong collaboration and stakeholder management skills, with the ability to work effectively across multidisciplinary and geographically distributed teams. Availability to work Monday through Friday, generally from 8:00 a.m. to 5:00 p.m. Central Time, with a 40-hour standard workweek. Ability to work remotely from within the contiguous United States and maintain a secure, dedicated workspace that complies with HIPAA and protects confidential member health information. Reliable home internet connection with minimum speeds of 25 Mbps download and 10 Mbps upload. Preferred qualifications: Knowledge of the managed care industry, including Medicare Advantage, Managed Medicaid, commercial health insurance, medical management organizations, hospitals, integrated delivery systems, or clinical group practices. Previous utilization management experience within a medical management organization, particularly in Medicare Advantage, Managed Medicaid, or commercial health insurance. Familiarity with nationally recognized clinical decision-support guidelines, such as MCG or InterQual. Clinical specialization in Family Medicine, Pediatrics, Physical Medicine and Rehabilitation, or Emergency Medicine. An advanced degree such as an MBA, MHA, or MPH. Exposure to public health, population health management, healthcare analytics, and the use of business performance metrics. Experience collaborating with case managers or care managers on complex case management, including familiarity with social determinants of health. Knowledge of value-based care models, healthcare quality improvement, and strategies for improving clinical and operational outcomes. Benefits: Annual base salary: $223,800–$313,100, depending on geographic location, relevant qualifications, professional experience, clinical expertise, and other job-related factors. Performance-based bonus: Eligibility for additional financial incentives based on individual and/or organizational performance. Medical coverage: Comprehensive healthcare benefits, including medical, dental, and vision insurance. Retirement savings: Access to a 401(k) retirement savings plan to support long-term financial planning. Paid time off: Paid vacation, personal time off, and company holidays. Family support: Paid parental and caregiver leave to support important family milestones and responsibilities. Disability coverage: Short-term and long-term disability insurance. Life insurance: Financial protection through life insurance benefits. Remote working flexibility: Fully remote position for candidates residing within the contiguous United States. Work-life balance: Standard Monday-to-Friday schedule, with some flexibility depending on operational requirements. Professional development: Opportunities to contribute to clinical leadership initiatives, quality improvement projects, and population health programs. Meaningful impact: Opportunity to influence healthcare quality, improve care coordination, and support better outcomes for Medicaid populations. Collaborative environment: Work alongside experienced physicians, clinical professionals, and regional healthcare leaders.