Medical Director

Priority Health; Grand Rapids (MI); On-site; USD 180,000 - 280,000; Full time

Job summary

Priority Health is seeking a Medical Director to lead clinical utilization decisions and collaborate with medical communities across Michigan. The role emphasizes evidence-based practice, patient-centered care, and cost-effective management within Priority Health’s mission and strategic goals.

The candidate will engage in peer discussions, participate in denials management, and contribute to population health discussions while maintaining board certification in a medical specialty and Michigan

Qualifications

• Doctorate in a medical field and MD or DO licensure in Michigan.
• Proven experience in clinical settings and managed care.
• Strong communication with physicians and education skills.
• Familiarity with utilization management principles and guidelines.

Responsibilities

• Understand Priority Health’s mission, goals, and value proposition.
• Provide clinical oversight to nurse case management and utilization management.
• Promote patient-centered care and evidence-based medicine.
• Contribute to clinical utilization guidelines and health management programs.
• Collaborate with medical directors and line-of-business leaders.

Skills

Physician communication

Utilization management

Evidence-based medicine

Clinical leadership

Education

Doctorate

Tools

InterQual

Milliman

Job description

We are the second largest and fastest growing health plan in Michigan focused on improving the health and lives across the state, and we couldn't do it without the incredible talent of our employees. It is their commitment that continues to drive our success as a nationally recognized nonprofit health benefits company. As part of the Corewell Health system, our team members have a unique ability to grow and advance their career while maintaining their seniority and benefits.

Scope of Work

The Medical Director role is critical to Priority Health's mission of improving health, inspiring hope and saving lives as we partner with medical communities. Expectations will include: A strong understanding of the guiding principles of; Right care, Right time, Right place, Right cost. This strong understanding of the guiding principles will be demonstrated through applications of evidence-based utilization review process and application of sound clinical judgement. The medical director will be part of the medical director teams and will work jointly with each of the lines of business leaders to assure compliant, evidence-informed decisions are provided. This position will have responsibilities including peer to peer clinical discussions, and participation in denials management which include review of previous clinical decisions by Priority Health Medical Directors (appeals). There will be opportunities to clinically contribute to discussions specific to populations health topics. Expectation to maintain Board Certification in a Medical or Surgical specialty from a nationally recognized specialty board. This position will be a strong contributor to support the mission and vision of Priority Health.

Essential Functions

Understand Priority Health’s mission, strategic goals, and value proposition for our communities and the people we serve.

Actively participate in support of medical management

Provide clinical oversight to nurse case management and utilization management.

Promote and advocate for patient-centered care, evidence-based medicine, and lower per-capita costs; participate in the development of clinical utilization guidelines, health management programs and clinical quality programs.

Promote evidence-base care standards with our community physician partners.

Qualifications

Required Doctorate

3 years of relevant experience in clinical setting. Required

3 years of relevant experience Managed care experience. Required

Proven experience and evidence of success in effective physician communication and education skills; evaluation of evidence-based standards of care and application of utilization management skills and strategies. Preferred

LIC-Physician (MD) - State of Michigan required Or

LIC-Osteopathic Physician (DO) - State of Michigan required within 90 days. Required.

Board Certification DO - AOA American Osteopathic Association upon hire Required OR

Board Certification MD - AMBS American Board of Medical Specialties upon hire Required OR

Board Certification MD_DO - AAHPM American Academy of Hospice & Palliative Medicine upon hire Required OR

Board Certification MD_DO - ABFAS American Board of Foot & Ankle Surgery upon hire Required OR

Board Certification MD_DO - ABOMS American Board of Oral & Maxillofacial Surgery upon hire Required OR

Board Certification MD_DO - ABPM American Board of Podiatric Medicine upon hire Required OR

Board Certification MD_DO - ABSM American Board of Sleep Medicine upon hire Required OR

Board Certification MD_DO-ABAM American Board of Addiction Medicine upon hire Required OR

Board Certification MD_DO-ASAM American Society of Addiction Medicine upon hire Required

Working knowledge of national utilization management tools such as InterQual and Milliman. Preferred