Medical Director - Midland States
Core
Provide oversight for medical policy implementation, utilization review, quality assurance, and clinical/medical program development for a national insurer.
Role type
Senior Medical Director (Utilization Management)
Builds
Medical management programs and clinical care pathways
Domain
Health Insurance / Utilization Management
Required skills
Medical policy implementation, utilization review, quality assurance, predetermination reviews, claim determinations, prior authorization, peer-to-peer calls, first-level appeals, case management, clinical expertise, coding expertise, reimbursement expertise, network provider liaison
Preferred skills
UM experience with Health Plan/Payor, Board Certification in Internal Medicine/Family Medicine/Emergency Medicine/Med Peds/General Surgery
Technologies
None stated
Responsibilities
Oversee utilization review and quality assurance, conduct predetermination reviews and claim determinations, manage prior authorization and peer-to-peer calls, lead clinical team activities, act as liaison to network providers
Seniority
Senior, hands-on IC