Medical Director, Utilization & Quality Management

Physician Pivot; Detroit (MI); On-site; USD 180,000 - 240,000; Full time

Job summary

Physician Pivot in Detroit is seeking a Medical Director to provide clinical leadership across the enterprise, interpret medical policy, and advise on program development to support high-quality care.

You will collaborate with physicians and non-clinical staff to lead utilization and quality initiatives, review complex cases, and guide disease-management programs while aligning with CMS, NCQA, and HEDIS standards.

Qualifications

• MD/DO from an accredited school is required.
• Seven years of clinical practice.
• Two years of medical director experience preferred.
• Current Michigan license as MD or DO.
• Board certification or board eligibility in a recognized specialty.
• Certification in Utilization Review and Health Care Quality & Management preferred.
• Ability to communicate effectively with external physicians and organizations.
• Proven leadership and ability to manage multiple priorities.
• Familiarity with HEDIS/STARs, NCQA, CMS regulations; CPT knowledge.

Responsibilities

• Provide clinical expertise across the enterprise and advise on policy and program development.
• Support utilization management, quality management, and care management programs; identify opportunities for efficiency.
• Lead disease state management and health enhancement program design and assessment.
• Provide clinical leadership for health promotion and education; support claims editing and related departments.
• Serve as SME to clinical and non-clinical staff and perform clinical reviews and peer-to-peer reviews.
• Discuss medical policies and utilization with BCBSM network physicians; review high-dollar and complex cases.
• Participate in inter-rater reliability activities and department committees to meet objectives.

Skills

Leadership

Communication

Problem solving

Strategic thinking

Education

MD/DO

Tools

Microsoft Office

Job description

Physician Pivot in Detroit is seeking a Medical Director to provide clinical leadership across the enterprise, interpret medical policy, and advise on program development to support high-quality care.

You will collaborate with physicians and non-clinical staff to lead utilization and quality initiatives, review complex cases, and guide disease-management programs while aligning with CMS, NCQA, and HEDIS standards.