Medical Director- Florida Medicare
Core
Lead utilization management and medical necessity reviews for inpatient and outpatient authorizations, appeals, and peer-to-peer clinical discussions to ensure compliance with Medicare and state regulations.
Role type
Director-level Medical Director (Utilization Management)
Builds
Utilization management programs and clinical review processes for Florida Medicare members and providers
Domain
US Healthcare / Medicare / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Utilization management, medical necessity review, peer-to-peer clinical discussions, committee leadership, policy interpretation, project leadership, cost of care initiatives, clinical guidelines application
Preferred skills
Medicare experience, Internal Medicine or Family Medicine training
Technologies
MCG, InterQual, CMS guidelines
Responsibilities
Perform utilization management reviews to determine medical necessity and appropriateness of care; Provide peer-to-peer discussions with treating physicians regarding medical necessity decisions; Participate in assigned committees including peer review, credentialing, and quality committees; Lead projects related to cost of care initiatives; Interpret medical policies and clinical guidelines; Ensure timely and accurate completion of reviews in compliance with regulations; Provide guidance for clinical operational aspects of the program
Seniority
Director, hands-on leadership with strategic oversight