Medical Director-Physical Health (Remote, North Carolina Based)

The Medical Management Team provides guidance and oversight of clinical services requested including authorization of services, operations, and overall clinical direction. The team is responsible for maintaining the integrity of the program, including initial and concurrent utilization reviews of services and procedures.

The Physical Health Medical Director assists with oversight of the clinical organization and application of service definition criteria and other standards of care for utilization management requests for services, procedures, and level of care. The individual in this position may be expected to work weekends as the need arise.

This position will allow the successful candidate to work full time remote. Candidates who are resident of North Carolina or willing to relocate are strongly preferred. Out of state candidates unable to relocate, will be considered on a case-by-case basis.

Responsibilities & Duties
 

Assist with the Development of Service Criteria and Other Standards of Care

• Make recommendations on the application of medical necessity criteria for level of care and service eligibility regarding type, amount, and duration of service
• Assist with developing the process to assess and document medical necessity

 Review Approval and Denial of Service Requests

• Review the approval and denial of care utilizing appropriate medical necessity guidelines
• Assist in functions and collaboration with department including, Utilization Management (UM), Quality Management (QM), Care Management (CM), Peer reviews, and Appeals
• Collaborates with physicians, psychologists, pharmacists, social workers, psychiatric nurses, or other professionals to discuss coordination and overall care of member

Provide Consultation and Training

• Provides consultation as well as training and education to staff and community partners on relevant topics

Develop Peers and Maintain a Positive Environment

• May train and mentor peers of the Medical Management team and PH- medical director new hires
• Work with Human Resources and Medical Team to attract, maintain, and retain a highly qualified and well-trained workforce
• Actively establish and promote a positive, diverse, and inclusive working environment that builds trust with teammates
• Ensure all staff are treated with respect and dignity
• Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members

Minimum Requirements

Education & Experience

Graduation from an accredited Medical School. M.D./D.O. degree is required and board certification in a relevant field. At least four (4) years of postgraduate clinical experience and two (2) or more years of managed care and utilization management experience are required.

Special Requirement

Current, active, and unrestricted license to practice medicine in …