Medical Director - OP Medicare
Core
Remote physician leadership role focused on complex outpatient utilization management for Medicare populations, applying clinical expertise to evaluate authorization requests, medical necessity, level of care, and site-of-service decisions.
Role type
Senior physician leadership (utilization management)
Builds
Utilization management determinations, care management strategies, and population health initiatives for Medicare populations
Domain
Healthcare / Medicare / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical judgment, regulatory compliance, evidence-based decision making, peer-to-peer discussion, care coordination, coding practices, population health strategies
Preferred skills
Managed care experience, Medicare Advantage experience, utilization management experience, familiarity with MCG or InterQual guidelines, healthcare analytics, advanced degree (MBA/MHA/MPH)
Technologies
CMS guidelines, Medicare policies, MCG, InterQual
Responsibilities
Review moderately complex to complex outpatient cases to determine authorization and medical necessity; Conduct utilization management reviews in accordance with CMS and Medicare guidelines; Analyze clinical documentation to make evidence-based coverage determinations; Collaborate with external physicians for peer-to-peer discussions and resolve disagreements; Participate in care management activities supporting quality outcomes and resource utilization; Provide clinical input on coding practices, documentation, and appeals processes; Partner with internal teams and provider groups to support market priorities; Contribute to value-based care and population health initiatives; Manage daily workloads independently while maintaining regulatory compliance.
Seniority
Senior, hands-on physician leadership