Lead Medical Director - Utilization Management & Policy

Remote Jobs; United States; Remote; USD 224,000 - 364,000; Full time

Benefits offered by this job

Medical, dental, vision

Life and disability insurance

Retirement plan with company match

Paid time off

Wellness program

Job summary

Florida Blue is seeking an experienced physician reviewer to lead utilization management activities across Pre-service, Post-service, and Concurrent Review. You will discuss cases with clinicians, apply strict review hierarchies, and collaborate with Case Managers to ensure timely, compliant decisions for medical necessity.

The role requires Florida licenses, board eligibility or certification, and 5+ years of clinical experience in a fast-paced environment.

Qualifications

• Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine.
• Board Certification or Board eligibility by American Board of Medical Specialties or equivalent.
• 5+ years of clinical experience.
• Experience working in a dynamic, fast-paced environment.
• Experience working both independently and in a team environment.
• Exceptional verbal and written communication

Responsibilities

• Perform all types of utilization management (UM) reviews, including Pre-service, Post-service, Concurrent Review and Appeals.
• Discuss cases with physician providers (Peer to Peer).
• Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests.
• Collaborate with Case Managers to provide support and guidance on cases needing physician assistance.
• Meet any established metrics related to UM review efficiency, timeliness, and quality of review.
• Participate in Inter-rater reliability (IRR) audits and health plan audits as necessary.
• Assist nurses and other staff in understanding principles behind utilization review and interpretation of benefits and policies.
• Participate in development/review of Medical and Pharmacy policies as assigned.
• Support the organization as a subject matter expert.
• Perform as lead Medical Director consultant for a sub-category of utilization management (e.g., commercial or Medicare).
• Perform other duties as assigned and needed by the organization.

Skills

Medical license

Board certification

Clinical experience

Verbal communication

Written communication

Team collaboration

Independent work

Job description

Florida Blue is seeking an experienced physician reviewer to lead utilization management activities across Pre-service, Post-service, and Concurrent Review. You will discuss cases with clinicians, apply strict review hierarchies, and collaborate with Case Managers to ensure timely, compliant decisions for medical necessity.

The role requires Florida licenses, board eligibility or certification, and 5+ years of clinical experience in a fast-paced environment.