Medical Director, Medical Management
Core
Physician leader ensuring utilization management responsibilities align with clinical standards by reviewing escalated cases for medical necessity and appropriateness.
Role type
Senior physician clinical operations lead (utilization management)
Builds
Utilization review decisions, case management protocols, and multidisciplinary care strategies
Domain
Health insurance / Managed care
Required skills
Clinical case review, Medical policy interpretation, Peer-to-peer consultation, Protocol development, Project management, Compliance adherence
Preferred skills
Managed care industry knowledge, Business administration or Public Health degree
Technologies
Clinical software, Electronic case review systems
Responsibilities
Conduct electronic review of escalated cases to determine medical necessity and appropriateness; Participate as a physician member of the multidisciplinary team for case and disease management; Advise the team on high-risk cases requiring physician expertise; Develop protocols and guidelines to ensure consistency in the review process; Manage projects requiring physician subject matter expertise
Seniority
Senior, hands-on IC with strategic advisory role
