Medical Director - OP Medicare

Accountabilities: Review moderately complex to complex outpatient cases and use clinical expertise and medical judgment to determine authorization, medical necessity, level of care, and appropriate site of service. Conduct utilization management reviews in accordance with CMS requirements, Medicare and Medicare Advantage guidelines, national clinical criteria, internal policies, regulations, and contractual obligations. Analyze clinical documentation and medical records to make accurate, evidence-based coverage and care determinations while meeting required turnaround times. Communicate clinical decisions and determinations clearly to internal teams and relevant stakeholders. Collaborate with external physicians to obtain additional clinical information, participate in peer-to-peer discussions, explain determinations, and resolve disagreements when necessary. Participate in care management activities supporting quality outcomes, care coordination, appropriate resource utilization, and improved member outcomes. Provide clinical input, as applicable, on coding practices, clinical documentation, grievance and appeals processes, and outpatient services or equipment reviews. Partner with internal teams, regional health services leadership, contracted physicians, provider groups, facilities, and community organizations to support market and organizational priorities. Contribute to initiatives involving value-based care, population health, disease management, and broader care management strategies. Manage daily workloads independently following training, maintaining high standards for quality, productivity, documentation, consistency, and regulatory compliance. Requirements MD or DO degree with at least 5 years of direct clinical patient care experience following residency or fellowship. Current and ongoing board certification in an approved ABMS medical specialty. Current, unrestricted medical license in at least one U.S. jurisdiction, with willingness to obtain additional licenses if required. Clinical experience preferably including outpatient care and/or care for Medicare-type populations, including adults over 65 or individuals with disabilities. Ability to meet credentialing requirements and no current sanctions from federal or state governmental organizations. Strong analytical and interpretive abilities, with sound judgment when evaluating clinical information and making coverage decisions. Excellent written and verbal communication skills and the ability to interact professionally with physicians, internal teams, and other stakeholders. Flexibility, intellectual curiosity, willingness to learn, and an interest in improving processes and adapting to change. Preferred experience with managed care, Medicare Advantage, Managed Medicaid, or commercial health insurance. Preferred utilization management experience within a medical management or health insurance environment. Familiarity with national clinical guidelines such as MCG or InterQual is advantageous. Experience with population health, public health, healthcare analytics, business metrics, or collaboration with case and care managers is beneficial. An advanced degree such as an MBA, MHA, or MPH is preferred. Benefits Salary: $223,800–$313,100 per year, with individual compensation varying based on location, skills, experience, education, and other job-related factors. Bonus: Eligibility for a performance-based incentive plan. Remote work: Nationwide remote position with typical Monday–Friday business hours and some flexibility based on business needs. Time off: Paid time off, company holidays, and personal holidays. Family support: Paid parental and caregiver leave. Healthcare: Medical, dental, and vision coverage. Retirement: 401(k) retirement savings plan. Insurance: Short-term and long-term disability and life insurance. Additional support: Whole-person wellness resources and other employee benefit opportunities. Work setup: Dedicated home workspace and reliable internet connection required; occasional travel for training or meetings may be expected.