Medical Director - Priority Health

Priority Health; Grand Rapids (MI); On-site; USD 250,000 - 350,000; Full time

Benefits offered by this job

Comprehensive benefits

On-demand pay

Discounts directory

Identity theft protection

Retirement options

Job summary

Priority Health in Grand Rapids seeks a Medical Director to provide clinical oversight across medical management and utilization review. You will collaborate with line-of-business leaders to ensure evidence-informed decisions and engage in denials management with priority to patient-centered care.

Candidates must hold an MD or DO with Michigan licensure and board certification as specified. The role emphasizes evidence-based standards, peer discussions, and advancing health outcomes within

Qualifications

• Doctorate/MD or DO license required.
• 3 years of clinical experience in a medical setting required.
• 3 years of managed care experience required.
• Evidence-based utilization review experience preferred.
• Board certification requirements listed by specialty and hospital hiring rules.

Responsibilities

• Provide clinical oversight to medical management and utilization reviews.
• Lead peer-to-peer clinical discussions and participate in denials management.
• Collaborate with line-of-business leaders to ensure compliant, evidence-informed decisions.
• Promote evidence-based care standards with community physician partners.
• Support the mission to improve health outcomes and reduce per-capita costs.

Skills

Clinical experience

Managed care

Physician communication

Education

MD or DO license

Job description

About Priority Health

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

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance
• Traditional and Roth retirement options with service contribution and match savings
• Eligibility for benefits is determined by employment type and status

Primary Location

SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids

Department Name

Medical Affairs - PH Managed Benefits

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8 a.m. to 5 p.m.

Days Worked

Monday to Friday

Weekend Frequency

Variable weekends

Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.