Medical Director

• Act as a clinical consultant and strategic partner to key employer group clients through a consultative, service-oriented clinical relationship to maximize client satisfaction, contract renewals, and adoption of new or expanded use of Quantum’s products and services.
• Participate in developing and delivering semiannual and annual reviews for client meetings to represent Quantum’s clinical operating model and actively support alignment between the clinical operating model and the clinical and benefit strategy for the client.
• Translate complex clinical trends and data into actionable insights for benefit strategy and wellness programming.
• Translate population health data into actionable, strategic recommendations tailored to client goals.
• Interpret medical and pharmacy claims, biometrics, and engagement data to identify cost drivers, care gaps, and population health risks.
• Recommend benefits and programs, as well as other interventions based on clinical data and ROI potential.
• Deliver clear, compelling presentations and reports on clinical outcomes and trends.
• Serve as the voice of the client’s health goals, ensuring that clinical programming aligns with workforce needs.
• Educate client stakeholders and brokers on trends in population health, cost containment, and value-based care.
• Serve as the primary point of escalation for complex client inquiries or concerns.
• Ensure that all clinical recommendations adhere to evidence-based guidelines and regulatory requirements.
• Provide clinical impact narratives and documentation to support renewal conversations and upsell opportunities.
• Support Account Managers in articulating the clinical value of services provided.
• Establishes criteria and protocols for standard medical treatment inquiries and renders determinations on requests for healthcare services and/or treatment.
• Conduct daily review of individual cases and have necessary case level conversations as requested. This includes prior authorizations and denial decisions for cases that do not meet established evidence-based criteria.
• Provide clear and concise documented medical review determinations and support on requested reviews within the established time frames.
• Provide clinical and nurse consultations.
• Identify opportunities to implement best practices approaches and introduce innovations to provide improved outcomes.
• Perform utilization review and case management support on complex members.
• Offer peer-to-peer discussions regarding determinations as necessary.
• Serve as a medical liaison to physicians, hospitals and insurance carriers.
• Provides determination on appeals for cases where they did not make the initial determination.

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