Medical Director

• Provide physician leadership in the development, implementation, and ongoing evaluation of evidence-based clinical guidelines, medical policies, and utilization management protocols to support high-quality, clinically appropriate decision-making.
• Ensure clinical programs, utilization review activities, and medical management processes align with current standards of care, evidence-based medicine, accreditation requirements, and applicable federal and state regulations.
• Serve as the clinical authority for complex, high-risk, or escalated utilization review cases by providing medical expertise, benefit interpretation, and final medical necessity determinations as appropriate.
• Promote consistency, accuracy, and defensibility in medical decision-making by applying sound clinical judgment and established medical necessity criteria across all review activities.
• Collaborate with Clinical Operations, Compliance, Legal, and executive leadership to develop, review, and revise clinical and administrative policies, medical necessity guidelines, and benefit interpretation criteria.
• Monitor changes in clinical practice guidelines, healthcare regulations, payer requirements, and industry best practices, recommending updates to organizational policies and review processes as necessary.
• Provide physician oversight for quality and performance initiatives by reviewing medical management outcomes, analyzing quality metrics, and participating in quarterly Quality Committee meetings and reporting.
• Participate in internal audits, accreditation activities, regulatory reviews, and quality improvement initiatives to ensure compliance with organizational standards and continuous operational excellence.
• Partner with operational leadership to ensure clinical standards are effectively integrated into utilization review workflows, promoting efficient, evidence-based, and member-focused medical management.
• Provide clinical consultation and recommendations regarding post-service medical necessity determinations, appeals, and other medically complex cases requiring physician review.
• Serve as a trusted clinical resource and advisor to physicians, nurses, utilization review staff, and cross-functional business partners by providing education, guidance, and consultation on medical policy and clinical best practices.
• Participate in interdisciplinary committees, physician advisory groups, and organizational meetings to provide clinical insight and support strategic initiatives.
• Foster collaborative relationships with internal and external stakeholders to promote quality outcomes, regulatory compliance, and continuous improvement across medical management programs.
• Perform other duties as assigned.

Medical Director – Part Time

• Design, structure, and develop long-term evolution of enterprise formulary and utilization management strategy.
• Accountable for the fiscal management of the department, including forecasting, budget development, ongoing variance monitoring, and trending.
• Serve as the authority on formulary strategy decisions, incorporating clinical evidence, market dynamics, and financial considerations.
• Provide clinical leadership in governance forums.
• Develop and lead clinical and formulary strategies aligned to organizational growth, client needs, and industry trends.
• Monitor emerging drug pipeline and therapeutic trends to proactively shape formulary positioning and strategy.
• Lead clinical strategy input for new business pursuits and client retention efforts.
• Foster cross-functional and inter-professional work teams to drive results in support of the strategic plan of the organization.
• Ensure formulary and clinical strategies align with regulatory requirements, accreditation standards, and internal policies.
• Design and oversee clinical criteria for prior authorizations, step therapy, and quantity limits to ensure appropriate medication use.
• Maintain accountability for clinical integrity and appropriateness of decision-making.
• Provide leadership, training, and supervision to team members.

Director, Clinical Strategy – RPh

• Oversee the performance and growth of Customer Service, Prescription Processing, Client-specific teams, managing both internal staff and external vendors
• Lead operational excellence across central fill pharmacy networks and courier delivery operations
• Lead your team with Key Performance Indicators (KPIs) to drive business success and increase efficiency while lowering the cost-to-fill on an annual basis
• Manage quality, turnaround time (TAT), and customer satisfaction metrics to ensure FuzeRx remains the preferred infrastructure partner for telehealth and pharma partners
• Establish requirements for capabilities and reporting, collaborating cross-functionally to deliver data-driven insights
• Analyze data to forecast staffing needs based on program performance, optimizing resource allocation across multiple roles
• Lead a large team of managers, supervisors and team members, establishing an environment of positive employee engagement and experience

Medical Director jobs in New Hampshire

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Medical Director – Part Time

Director, Clinical Strategy – RPh

Director, Rx Clinical Operations