Medical Director
Core
Provides clinical expertise, oversight, and strategic guidance for medical management functions, including appeals, rescissions, grievances, and DOI complaints within health insurance products.
Role type
Director-level physician (Medical Director)
Builds
Clinical review processes, coverage determinations, and medical management programs for health insurance
Domain
Health insurance / Medical management / Regulatory compliance
Required skills
Clinical judgment, regulatory compliance, policy interpretation, risk selection, process improvement, cross-functional partnership, AI integration, quality assurance, trend analysis, executive advisory
Preferred skills
Health insurance/managed care experience, appeals/grievances expertise, legal/compliance partnership, clinical process leadership, strategic business decision support, product design input
Technologies
Microsoft Office suite, AI/automation tools, TPA systems
Responsibilities
Provide clinical oversight for appeals, rescissions, and grievance panels; Conduct complex clinical reviews for coverage determinations; Partner with legal and compliance on regulatory matters; Drive AI and process improvements in medical review workflows; Advise executive leadership on risk and product strategy; Ensure consistency in clinical decision-making across the organization
Seniority
Director, hands-on IC with supervisory duties