Medical Director - Individual Segment
Core
Lead clinical policy development, utilization review, and program implementation for individual health plans, ensuring medical necessity determinations and benefit decisions.
Role type
Senior IC Medical Director (Utilization Management)
Builds
Clinical review processes, medical policies, and utilization management programs for individual health plan members.
Domain
US Healthcare / Managed Care / Utilization Review
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical policy development, utilization review/management, peer-to-peer clinical reviews, medical necessity evaluation, benefit determinations, process improvement, cost-of-care analysis, committee leadership, innovation in healthcare quality.
Preferred skills
Managed care experience, utilization management review experience, internal medicine or family practice clinical background.
Technologies
None explicitly stated
Responsibilities
Develop and interpret medical policies and clinical guidelines; conduct peer-to-peer clinical reviews and appeals with providers; oversee clinical and non-clinical activities impacting care quality and cost; lead program development and implementation; serve as a consultant to other company areas; represent the company on internal and external committees.
Seniority
Director level, hands-on leadership with strategic oversight