Medical Director - Physical Health

Accountabilities:: Review and evaluate moderately complex to highly complex clinical cases, using medical expertise and professional judgment to determine whether requested services, levels of care, and treatment settings should be authorized. Apply relevant clinical guidelines, state Medicaid policies, CMS regulations, and other evidence-based resources to ensure consistent, compliant, and medically appropriate determinations. Develop a strong understanding of Medicaid requirements within the assigned regional cluster and translate regulatory and clinical guidance into daily operational practices. Review submitted medical records, prioritize daily workloads, communicate clinical decisions to internal teams, and support care management activities when needed. Conduct peer-to-peer discussions with external physicians to gather additional clinical information, explain medical determinations, and facilitate constructive resolution of disagreements. Collaborate with contracted physicians, medical groups, healthcare facilities, and community organizations to support regional priorities and strengthen provider relationships. Contribute to value-based care, population health, disease management, and care management initiatives that improve healthcare quality and member outcomes. Support organizational values and initiatives focused on addressing members' social needs and improving access to appropriate care. Provide coverage across the assigned regional cluster when necessary, including during vacations, weekends, and holidays. Requirements: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree. Board certification in a medical specialty recognized by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA). At least five years of post-training clinical experience providing direct patient care. Current, unrestricted medical license in at least one state within the assigned regional cluster, with the ability to obtain unrestricted licensure in the remaining applicable states: Indiana, Ohio, Kentucky, Virginia, Wisconsin, and Illinois. Experience working with Medicaid members, healthcare providers, and relevant stakeholders in clinical or administrative settings. Experience in utilization management, clinical reviews, and case management within a health plan or similarly regulated healthcare environment. Strong understanding of clinical decision-making, medical necessity assessments, regulatory requirements, and evidence-based clinical guidelines. Excellent analytical, problem-solving, and decision-making abilities, with the confidence to assess complex clinical situations and communicate recommendations effectively. Strong written and verbal communication skills, including the ability to conduct physician-to-physician discussions and manage challenging conversations professionally. Ability to work independently while collaborating effectively with multidisciplinary teams and regional stakeholders. Must meet all onboarding and credentialing requirements and have no active sanctions from federal or state governmental organizations. Familiarity with NCQA accreditation processes and experience using CGX and MHK systems are highly desirable. Interstate Medical Licensure Compact (IMLC) participation or licensure is preferred. Benefits: Competitive annual base salary ranging from $223,800 to $313,100, depending on qualifications, experience, and geographic location. Eligibility for an additional performance-based bonus incentive. Comprehensive medical, dental, and vision insurance coverage. 401(k) retirement savings plan. Paid time off, company holidays, and personal holidays. Paid parental and caregiver leave. Short-term and long-term disability coverage. Life insurance and additional employee well-being benefits. Fully remote work arrangement within the eligible regional states. Standard Monday-to-Friday schedule, with typical business hours starting no later than 9:00 AM Eastern Time and some flexibility depending on business needs. Opportunities to collaborate with multidisciplinary healthcare professionals and contribute to meaningful Medicaid care initiatives. Occasional travel to company offices may be required for meetings or training.