This remote medical director role focuses on utilization review, quality assurance, and medical policy oversight for members across the care continuum. The clinician reviews prior authorizations, precertification requests, concurrent reviews, predetermination and claim determinations, first-level appeals, and peer-to-peer cases. The role also involves providing clinical, coding, and reimbursement guidance, supporting case management, and serving as a liaison to network providers and facilities.
Key Responsibilities
- Provide oversight for medical policy implementation and medical management programs.
- Conduct utilization review and quality assurance activities, including prior authorization and precertification reviews.
- Review concurrent cases, predetermination requests, claim determinations, and first-level appeals.
- Participate in peer-to-peer calls, committee work, and special projects as needed.
- Provide clinical, coding, and reimbursement expertise to support medical management decisions.
- Direct case management activities when necessary.
- Coordinate with medical management staff to ensure timely and consistent responses to members and providers.
- Serve as a clinical and business liaison to network providers and facilities.
Required
- MD or DO degree.
- Active, current state medical license without encumbrances.
- Board certification in an ABMS- or AOA-recognized specialty.
- At least 5 years of experience in health care delivery, clinical practice, or the health care industry.
- Post-graduate direct patient care experience.
Preferred
- Previous utilization management experience with a health plan or payer.
- Florida medical licensure preferred.
Benefits & Perks
- Remote work from home.
- Full-time position.
- Eligible for medical, dental, and vision coverage.
- Paid time off and retirement savings options.
- Wellness programs and other employee resources.
- Eligible for bonus, commission, or short-term incentive program.
- Eligible for an equity award target.