Medical Director

Teamware Solutions Inc.; United States; Remote; USD 180,000 - 240,000; Full time

Job summary

Teamware Solutions Inc. is seeking a Medical Director to review escalated medical cases, determine medical necessity, and ensure compliance with clinical guidelines and health care regulations.

This 100% remote leadership role involves collaboration with multidisciplinary teams and guiding policy development. The ideal candidate holds an MD or DO, active license in PA/NY/WV, board certification, 5+ years of direct patient care, and UM experience in payer settings, with familiarity with

Qualifications

• MD or DO degree required.
• Minimum 5 years of direct patient care experience.
• Active medical license in Pennsylvania, New York, or West Virginia.
• Board certification through an ABMS- or AOA-recognized specialty board.
• Strong utilization management (UM) experience in health insurance/payer settings preferred.
• Experience with MCG or InterQual criteria.

Responsibilities

• Review escalated medical cases and determine medical necessity.
• Evaluate appeals and grievances.
• Ensure compliance with clinical guidelines and healthcare regulations.
• Collaborate with multidisciplinary teams and support policy development.
• Conduct peer-to-peer reviews and contribute to clinical governance.

Skills

UM experience on payer side

Peer-to-peer reviews

Cross-functional collaboration

Clinical policy development

Education

MD or DO degree

Board certification ABMS/AOA

Active medical license in PA/NY/WV

Master's in Business Admin/Management/Public Health

Tools

MCG criteria

InterQual criteria

Predicta

Beacon review systems

Job description

Job Title: Medical Director – Location: 100% Remote

Job Description

Client is seeking a Medical Director to review escalated medical cases, determine medical necessity, evaluate appeals and grievances,and ensure compliance with clinical guidelines and healthcare regulations. The role involves collaborating with multidisciplinary teams,conducting peer-to-peer reviews, and supporting clinical policy development.

Required Qualifications

• MD or DO degree.
• Minimum 5 years of direct patient care experience.
• Board certification through an ABMS- or AOA-recognized specialty board.
• Active medical license in Pennsylvania, New York, or West Virginia.
• Strong utilization management (UM) experience on the health insurance/payer side is highly preferred. Hospital-based UM experience alone is not sufficient.
• Master's degree in BusinessAdministration,Management, or PublicHealth.
• At least 1 year of medical management experience with a health insurance plan.
• Experience with MCG or InterQual criteria.

Additional Requirements

• Must complete the Medical DirectorAssessment.
• Expected to review 55+ cases per 8-hour workday.
• Experience with Predicta and Beacon review systems is relevant.
• Candidates must be categorized as Behavioral Health or Non-Behavioral Health (Physical Health)duringsubmission