Medical Director, Care Management & Utilization (Remote)

Florida Blue Group; Town of Florida (NY); Remote; USD 224,000 - 364,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Disability benefits

Retirement Savings Plan

Paid time off

Holidays and well-being days

Job summary

Florida Blue Group seeks an experienced Medical Director to lead utilization management reviews across pre-service, post-service, and concurrent pathways. You will discuss cases with physicians, apply policy hierarchies for medical necessity decisions, and mentor teams in benefits interpretation.

You will bring Florida license, ABMS certification, and 5+ years of clinical experience to a fast-paced, collaborative environment offering comprehensive benefits and a competitive salary range.

Qualifications

• Current unrestricted Florida medical license as MD or DO.
• Board Certification or eligibility by ABMS or equivalent.
• Minimum 5 years of clinical experience in a fast-paced environment.
• Ability to work independently and in a team.
• Strong communication skills, both verbal and written.

Responsibilities

• Perform all types of utilization management reviews, including Pre-service, Post-service, Concurrent Review and Appeals.
• Discuss cases with physician providers (Peer to Peer).
• Apply health plan review hierarchy to render timely medical necessity decisions.
• Collaborate with Case Managers to support cases needing physician input.
• Meet metrics on compliance, accreditation, timeliness and quality of review.
• Participate in IRR audits and plan audits as needed.
• Assist nurses and staff in understanding utilization review principles and policies.
• Contribute to Medical and Pharmacy policy development and review.
• Serve as a subject matter expert for the organization.
• Perform as lead Medical Director consultant for a sub-category (e.g., commercial or Medicare).
• Perform other duties as assigned.

Skills

Clinical experience (5+ years)

Verbal and written communication

Independent and team work

Utilization management knowledge

Peer-to-peer discussion with physician

Education

Florida medical license (MD/DO)

Board Certification or Eligibility (ABMS)

Job description

Florida Blue Group seeks an experienced Medical Director to lead utilization management reviews across pre-service, post-service, and concurrent pathways. You will discuss cases with physicians, apply policy hierarchies for medical necessity decisions, and mentor teams in benefits interpretation.

You will bring Florida license, ABMS certification, and 5+ years of clinical experience to a fast-paced, collaborative environment offering comprehensive benefits and a competitive salary range.