Medical Director

MedStar Health; Raleigh (NC); Remote; USD 200,000 - 300,000; Full time

Job summary

A leading healthcare organization is seeking a Medical Director to oversee medical management functions, enhance quality improvement initiatives, and ensure compliance with regulations. This remote position requires an MD or DO with a strong background in utilization management and healthcare leadership. The role encompasses providing expertise in clinical practice, collaborating with stakeholders, and leading performance improvement initiatives.

Qualifications

• Medical Doctor or Doctor of Osteopathy with board certification.
• Utilization management experience with a minimum of 1 year required.
• Experience treating diverse populations preferred.

Responsibilities

• Direct and coordinate medical management and credentialing functions.
• Provide medical leadership for quality improvement initiatives.
• Conduct reviews for medical necessity and ensure compliance with regulations.

Skills

Utilization Management

Medical Leadership

Stakeholder Collaboration

Quality Improvement

Regulatory Knowledge

Education

Medical Doctor or Doctor of Osteopathy

Board certification in a medical specialty

Course work in Health Admin, Financing, Insurance

Job description

Position Title: Medical Director

Work Location: Remote - Nationally Sourced

Assignment Duration: 6 months with potential to extend or convert

Work Schedule: 8 am - 5 pm in candidate's time zone (EST, CST, PST)



Position Summary:

* Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.

Key Responsibilities:

* Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.

* Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.

* Supports effective implementation of performance improvement initiatives for capitated providers.

* Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.

* Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.

* Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.

* Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.

* Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.

* Participates in provider network development and new market expansion as appropriate.

* Assists in the development and implementation of physician education with respect to clinical issues and policies.

* Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.

* Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.

* Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.

* Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.

* Develops alliances with the provider community through the development and implementation of the medical management programs.

* As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.

* Represents the business unit at appropriate state committees and other ad hoc committees.

* May be required to work weekends and holidays in support of business operations, as needed.

* Performs other duties as assigned

* Complies with all policies and standards

Qualification & Experience:

* Medical Doctor or Doctor of Osteopathy

* Utilization Management experience

* Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services (Psychiatry if Behavioral Health)

* Current state medical license without restrictions

* Course work in Health Admin, Financing, Insurance preferred

* Experience treating or managing care for culturally diverse population preferred

Candidate Requirements
Education/Certification	Required: Medical Doctor or Doctor of Osteopathy. Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services.	Preferred:
Licensure	Required: need to be licensed	Preferred:
Years of experience required Disqualifiers Best vs. average Performance indicators	Must haves: UM experience (minimum of 1 year experience) Nice to haves: Medicare UM experience Extensive state licensing Disqualifiers: Not meeting the board certification Performance indicators: Production capacity around the 45 cases per day Quality of the review A strong candidate would meet the following: Clinical Expertise: Board-certified physician with active practice experience. UM Proficiency: Proven ability to handle high-volume case reviews efficiently and accurately. Behavioral Health Experience: Especially valuable if applying for roles requiring psychiatry certification. Tech Savvy: Comfortable using EMR systems and collaborating virtually. Adaptability: Can work independently in a remote setting while engaging with a dynamic team. Regulatory Knowledge: Familiarity with accreditation standards and state-specific requirements.