Medical Director

• Oversees the administration of behavioral health services to ensure members receive appropriate, high-quality, and cost-effective care
• Provides clinical consultation and strategic guidance to strengthen clinical operations
• Supports the design and implementation of initiatives that improve quality, outcomes, and affordability
• Identifies and develops opportunities for innovation to increase effectiveness and quality
• Conducts peer-to-peer clinical reviews with attending physicians or other providers
• Serves as a resource and consultant to other areas of the company
• Attends Behavioral Health interdisciplinary team (IDT) meetings and other team-related meetings regularly

Behavioral Health Medical Director – Psychiatrist

• Reporting to the Department Administrator, assists with the global administration of the outpatient clinics through the management, coordination, and/or assessment of integrated clinic operations.
• Assesses and supports clinical efficiencies and enhancements, operational systems, contingency staffing, staff training, strategic operational performance, and patient experience.
• Participates in strategic and operational decision making as a member of the management team.
• Performs assessments of outpatient clinical operations and makes recommendations for operational enhancements and clinical efficiencies.
• Manages assigned clinical management and their teams; oversees the onboarding process for new managers in ambulatory clinics.
• Provides day to day operational management support in a clinic in the absence of a manager.
• Represents the LLC at various policy-making and/or operating committees.
• Assists in and provides input for determining strategic objectives, program and project development related to the outpatient clinics.
• Works in collaboration with Administrator and clinic management to develop, communicate and administer written policies, procedures, and protocols.

Director of Clinical Operations – Eye Physicians

• Leverage your background in Pain Medicine disciplines to deliver evidence-based medical reviews that support high-quality patient care.
• Collaborate with healthcare providers and stay current on healthcare regulations and industry developments as you review a wide range of cases.
• Start training remotely in a structured environment with support from trainers, mentors, and leadership to set you up for success.
• Complete time-sensitive, specialized evidence-based medical case reviews for medical necessity on EviCore’s case management software.
• Conduct physician consultation (peer-to-peer) calls with referring providers to discuss evidence–based medical necessity and appropriateness of the requested service or treatment.
• Leverage your clinical expertise to recommend alternative services or treatments as necessary.
• Work collaboratively with over 500 EviCore physician colleagues to help ensure patients receive proper care via evidence-based decision making.

Medical Director – Pain Medicine

• Responsible for appeal reviews for physical health medical services
• Ensure the appropriate and most cost-effective medical care is received
• Develop and implement programs to improve quality, cost, and outcomes
• Provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations
• Identify cost of care opportunities
• Supports clinicians to ensure timely and consistent responses to members and providers
• Provides guidance for clinical operational aspects of a program
• Conduct peer-to-peer clinical case reviews with attending physicians or other ordering providers
• Serve as a resource and consultant for other areas of the company

Medical Director – Oncology

• Responsible for the appeal reviews for physical health medical services
• Supports clinicians to ensure timely and consistent responses to members and providers
• Provides guidance for clinical operational aspects of a program
• Conducts peer-to-peer clinical case reviews with attending physicians
• Serves as a resource and consultant for other areas of the company
• May chair company committees
• Interprets medical policies and clinical guidelines
• Identifies and develops opportunities for innovation to increase effectiveness and quality

Appeals Medical Director – Cardiology

• The Director of Clinical Services (DCS) is accountable for clinical and operational excellence within a defined book of business in an Envision Physician Services operating unit.
• This position drives improvements in patient care processes and outcomes by partnering with local practice medical leadership and front-line clinicians.
• Within a defined book of business, the DCS balances the needs and opportunities of a client with internal EMG relationships throughout their portfolio.
• The DCS identifies areas of opportunity within their book of business and works collaboratively with operating unit leadership team to provide partnership to medical directors and clients towards performance enhancement and goal achievement.
• The DCS drives implementation of clinical quality, service line clinical operations, corporate initiatives.

Director of Clinical Services

• Responsible for appeal reviews for physical health medical services
• Ensure appropriate and cost-effective medical care is received
• May develop and implement programs to improve quality, cost, and outcomes
• Provide clinical consultation and serve as clinical/strategic advisor
• Identify cost of care opportunities
• Supports clinicians for timely and consistent responses to members and providers
• Provides guidance for clinical operational aspects of a program
• Conduct peer-to-peer clinical case reviews
• Serves as a resource and consultant for other areas of the company
• May represent the company to external entities and serve on committees
• Interprets medical policies and clinical guidelines
• May develop and propose new medical policies
• Leads, develops, directs, and implements clinical and non-clinical activities

Appeals Medical Director – Urology

• Develop and manage the Clinical Policy, Regulatory, and Compliance functions within the Office of Clinical Affairs.
• Ensure clinical operations meet healthcare laws and standards.
• Develop and maintain regulatory policies.
• Manage compliance risks and guide policy-related submissions.
• Advise senior leadership and work closely with teams across the organization.

Medical Director, Clinical Regulatory Affairs

• You’ll start training remotely in a structured environment with support from trainers, mentors, and leadership to set you up for success.
• Complete time-sensitive, specialized evidence-based medical case reviews for medical necessity on EviCore’s case management software.
• Conduct physician consultation (peer-to-peer) calls with referring providers to discuss evidence–based medical necessity and appropriateness of the requested service or treatment.
• Leverage your clinical expertise to recommend alternative services or treatments as necessary.
• Work collaboratively with over 500 EviCore physician colleagues to help ensure patients receive proper care via evidence-based decision making.

Medical Director – Medical Genetics, Genomics

• Have program management responsibilities including clinical policy development
• Oversee clinical/non-clinical activities
• Responsible for utilization review/management
• Develop and implement programs to improve quality, cost, and outcomes
• Conduct peer-to-peer clinical reviews with attending physicians
• Serve as a resource and consultant to other areas of the company
• Interpret medical policies and clinical guidelines
• Lead and develop clinical and non-clinical activities

• Determines the medical necessity of requests using clinical criteria
• Performs physician-level case review of oncologic utilization requests
• Conducts peer-to-peer consultation with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging and appropriate sites of service
• Provides education regarding applicable clinical criteria and discusses clinically appropriate options
• Performs first level provider appeals for coverage decisions
• Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate diagnoses, treatments, and management related to these specialties
• Participates in physician team meetings
• Participates in groups that develop, revise and enhance clinical appropriateness guidelines

Medical Director – Genetic Testing, Oncology

• uses their medical background, experience, and judgement to determine whether requested services, level of care, or site of service should be authorized
• learns Medicaid requirements and operationalizes this knowledge in daily work
• conducts computer-based review of moderately complex to complex clinical scenarios
• reviews all submitted clinical records, prioritizes daily work, communicates decisions to internal associates
• participates in care management, with clinical scenarios arising from outpatient or inpatient environments
• conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations
• may require conflict resolution skills
• may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities
• supports Humana values and our enterprise social needs team mission throughout all activities
• flows to work as needed within cluster for vacations, weekends, and holiday coverage

Physical Health Medical Director

• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit
• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services
• Supports effective implementation of performance improvement initiatives for capitated providers
• Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members
• Provides medical expertise in the operation of approved quality improvement and utilization management programs
• Assists the Chief Medical Director in the functioning of the physician committees
• Conduct regular rounds to assess and coordinate care for high-risk patients
• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals
• Participates in provider network development and new market expansion as appropriate
• Assists in the development and implementation of physician education with respect to clinical issues and policies
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice
• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
• Develops alliances with the provider community through the development and implementation of the medical management programs
• May represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues
• May be required to work weekends and holidays in support of business operations, as needed

Medical Director, Appeals

• Responsible for behavioral health care strategy and/or operations
• Make determinations on requested services and level of care authorization
• Conduct discussions with external physicians for additional clinical information
• Support regional market priorities through collaboration with clinicians and community groups
• Flow to work as needed for coverage during vacations, weekends, and holidays.

Behavioral Health Medical Director

• Oversee the administration of behavioral health services
• Provide clinical consultation and strategic guidance
• Ensure timely and consistent responses to members and providers
• Conduct peer-to-peer clinical reviews
• Serve as a resource and consultant to other areas of the company

• Completing medical necessity reviews for substance use disorder cases
• Supporting clinicians for timely responses to members and providers
• Providing clinical operational guidance
• Conducting peer-to-peer clinical reviews

Medical Director – Addiction Medicine

• Responsible for the administration of physical and/or behavioral health medical services
• Supports clinicians to ensure timely and consistent responses to members and providers
• Conducts peer-to-peer clinical reviews
• Identifies and develops opportunities for innovation to increase effectiveness and quality

Medical Director – Family/Internal Medicine

• Serves as a key clinical resource for staff
• Establishes criteria and protocols for standard medical treatment inquiries and renders determinations on requests for healthcare services and/or treatment
• Conducts daily review of individual cases and has necessary case level conversations as requested. This includes prior authorizations and denial decisions for cases that do not meet established evidence-based criteria
• Provides clear and concise documented medical review determinations and support on requested reviews within the established time frames
• Provides clinical and nurse consultations
• Identifies opportunities to implement best practices approaches and introduce innovations to provide improved outcomes
• Performs utilization review and case management support on complex members
• Provides support over the phone, through messaging and video to support chronic disease management
• Offers peer-to-peer discussions regarding determinations as necessary
• Serves as a medical liaison to physicians, hospitals and insurance carriers
• Provides determination on appeals for cases where they did not make the initial determination
• Utilizes data resources and tools that help our team provide personalized care to our clients
• Evaluates and interprets data. Identifies areas for improvement with a focus on interventions to improve client outcomes
• All other duties as assigned.

Medical Director, Clinical Specialty

• Assume the administrative authority, responsibility, and accountability of developing and implementing our PM&R program, policies, and procedures
• Coordinate medical care, including emergency treatment procedures
• Maintain effective liaison with attending physicians
• Implement methods to keep the quality of care under constant surveillance
• Provide necessary physician services for those residents in skilled nursing facilities and/or clinic environment

Medical Director, Physical Medicine and Rehabilitation (PM&R), Physiatry

• Responsible for the overall safety of patients with a BH diagnosis, with a special focus on safe prescribing
• Support Ohio Behavioral Health Market team program design and development and strengthening community collaboration
• Supervise part time Behavioral Health Medical Directors
• Serve as the clinical lead in developing and implementing evidenced based clinical policies and practices
• Assume key role in quality improvement initiatives, case management activities and member safety activities
• Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
• Provide provider education, training, data sharing, performance evaluations and orientation to the plan
• Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards
• Participate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives
• Collaborate with market/product leaders to help define market strategy
• Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate
• Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
• Provide cross-coverage for other Medical Directors and/or markets, as needed
• Provide prior authorization medical reviews, consultation, and clinical review services
• Conduct clinical reviews for designated CareSource members
• Identify utilization management trends and take appropriate action
• Support market provider network development and maintenance Clinical Appeals
• Participate in peer-to-peer discussions
• Support staff by providing training, clinical consultation, and clinical case review for members
• Perform any other job duties as requested

See all jobs on JobTailor

Behavioral Health Medical Director – Psychiatrist

Director of Clinical Operations – Eye Physicians

Medical Director – Pain Medicine

Medical Director – Oncology

Appeals Medical Director – Cardiology

Director of Clinical Services

Appeals Medical Director – Urology

Medical Director, Clinical Regulatory Affairs

Medical Director – Medical Genetics, Genomics

Medical Director

Medical Director – Genetic Testing, Oncology

Physical Health Medical Director

Medical Director, Appeals

Behavioral Health Medical Director

Behavioral Health Medical Director – Psychiatrist

Medical Director – Addiction Medicine

Medical Director – Family/Internal Medicine

Medical Director, Clinical Specialty

Medical Director, Physical Medicine and Rehabilitation (PM&R), Physiatry

Enterprise Medical Director – Behavioral Health