Medical Director - Capstone Market
Core
Provide oversight for medical policy implementation, development, and evaluation of clinical/medical programs to address member needs across the continuum of care.
Role type
Senior Medical Director (Utilization Management)
Builds
Medical management programs and utilization review/quality assurance processes
Domain
Health Insurance / Utilization Management
Required skills
Clinical expertise, Utilization review, Quality assurance, Predetermination reviews, Prior authorization, Pre-certification, Concurrent reviews, Peer-to-peer calls, First-level appeals, Case management, Network provider liaison
Preferred skills
UM experience with a Health Plan/Payor
Technologies
None stated
Responsibilities
Oversee utilization review and quality assurance; conduct predetermination reviews; manage prior authorization, pre-certification, and concurrent reviews; handle peer-to-peer calls and first-level appeals; support case management; act as clinical liaison to network providers.
Seniority
Senior, hands-on IC