Remote Medical Director, Utilization & Clinical Policy

WellSense Health Plan; Northern (KY); Hybrid; USD 173,000 - 250,000; Full time

Job summary

WellSense Health Plan is seeking a Medical Director to lead daily medical necessity reviews, evaluate policy, and oversee utilization management activities in a compliant, data-driven manner.

They will collaborate with senior medical leadership and physicians to ensure consistent decision making, support quality initiatives, and provide input to strategic planning for the Office of Clinical Affairs. This role requires MD/DO, extensive managed care experience, and licensure in MA/NH.

Qualifications

• MD or DO from an accredited medical school.
• 8-10+ years related experience incl. 5 years direct clinical and 3+ years in medical management in managed care.
• Board certification in Internal Medicine, Internal Medicine-Pediatrics, or Family Medicine preferred.
• ABMS/AOA board certification and current unrestricted licensure in MA/NH or ability to obtain in a reasonable timeframe.
• Pre-employment background check; no restrictions on Medicare/Medicaid participation.

Responsibilities

• Provide clinical case review and oversight for utilization management.
• Review prior authorizations, concurrent and retrospective reviews to determine coverage.
• Apply InterQual criteria and Medical Policy consistently.
• Collaborate with physicians and nurse case managers to improve population health and reduce costs.
• Chair clinical committees and support quality and pharmacy committees.
• Contribute to strategic planning for the Office of Clinical Affairs.

Skills

Clinical judgment

Communication

NCQA knowledge

InterQual/HEDIS knowledge

Medicare/Medicaid knowledge

Leadership

Managed care

Independent work

Quality turnaround

Education

MD/DO

Job description

WellSense Health Plan is seeking a Medical Director to lead daily medical necessity reviews, evaluate policy, and oversee utilization management activities in a compliant, data-driven manner.

They will collaborate with senior medical leadership and physicians to ensure consistent decision making, support quality initiatives, and provide input to strategic planning for the Office of Clinical Affairs. This role requires MD/DO, extensive managed care experience, and licensure in MA/NH.