Medical Director (PRN)
Core
Provide medical leadership for utilization management and medical review activities, including case reviews, appeals, and determining medical necessity for complex services.
Role type
Senior IC medical director (utilization management)
Builds
Utilization review programs and quality improvement initiatives for health plan members
Domain
Healthcare administration / Utilization management
Required skills
Board certification, active state medical license, utilization management experience, medical review of complex services, claims adjudication, clinical quality improvement, trend analysis, policy development
Preferred skills
Managed care organization experience, health administration/financing knowledge, experience with culturally diverse populations, multi-state licensure
Technologies
None stated
Responsibilities
Perform case reviews and appeals for all health plans; Assist CMO in planning goals and policies to improve quality and cost-effectiveness; Identify utilization review studies and evaluate adverse trends; Review claims involving complex or new services to determine medical necessity
Seniority
Senior, hands-on IC