Medical Director

• Provides strategic clinical oversight and support of the day-to-day clinical community operations to Executive Directors, Health and Wellness Directors and clinical associates
• Supports the company goals and strategies and optimizes resources to ensure quality care and service delivery, training and development of staff, and management of risk and regulatory compliance
• Responsible for the successful implementation and maintenance of community support center clinical policies and procedures
• Conducts regular clinical quality audits through community site visits and audits of all health care areas to ensure compliance with Brookdale standards and state regulations
• Analyzes specific community models to support staffing of clinical positions based on community size and residents receiving services
• Supports the implementation of quality care and services and encourages the development of medical professional relationships within the community
• Oversight of community survey readiness for regulatory compliance
• Monitors compliance and assists communities in root cause and corrective action of community quality metrics and clinical outcomes
• Analyzes resident incident reports and supports the community in corrective action plans as appropriate
• Verifies that a Community Care Conference and Collaborative Care Process is in place in accordance with policy
• Reviews resident clinical assessments to validate accuracy of resident’s physical, emotional and mental functioning
• Ensures the CARE process is being executed appropriately to address controllable resident move outs
• Provides clinical guidance to field staff, when necessary, to determine appropriate level of care for resident move-ins
• Supports the community’s overall resident/family satisfaction level as related to clinical care and impact to the overall community
• Participates in hiring, training, and mentoring of Health and Wellness Directors and other field level clinical associates

District Director of Clinical Services, RN

• Develop, implement, educate and monitor clinical programs
• Advise and support facilities in compliance with regulations
• Assist in response to disease outbreaks
• Monitor compliance with POC’s for recertification
• Provide training to facility Administration and staff
• Conduct visits to assess and train clinical staff
• Develop tracking and trending reports for clinical metrics
• Assist facilities in their clinical risk management efforts

Assistant Regional Director, Clinical Services

• Providing Migraine therapeutic area/product expertise for stakeholders
• Planning and executing independent Medical strategies and engagements
• Maintaining up-to-date knowledge of relevant TA/disease states and Pfizer medicines
• Serving as a resource for Medical Information and stakeholder insights
• Educating stakeholders based on patient care gaps
• Achieving leadership-defined expectations regarding external medical stakeholder engagement

Director, Internal Medicine – Field Medical Migraine

• Provides administrative oversight to the medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on medical policies
• Writes and revises medical policies
• Supports operations in case review on medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Educates staff and medical community on medical policy and program administration
• Develops and updates medical policy in consultation with regulatory personnel, medical consultants, and professional societies
• Develops external relationships with the medical community
• Reviews physician and provider practice pattern analysis and statistical data related to medical service utilization
• Conducts research into new or controversial medical procedures and technology

Physical Medicine and Rehabilitation Medical Director

• Provide Migraine therapeutic area/product expertise to external medical stakeholders
• Plan and execute independent Medical strategies and engagements for external medical stakeholders
• Maintain required level of knowledge of relevant TA/disease states and Pfizer medicines
• Serve as a conduit for Medical Information and external medical stakeholder insights
• Contribute to Medical educational content strategy development
• Conduct activities in accordance with all relevant policies, procedures and compliance guidance
• Educate external medical stakeholders based on patient care gaps
• Achieve leadership-defined expectations regarding stakeholder engagement
• Provide truthful, accurate, and scientifically supported information to stakeholders
• Cultivate research and therapeutic area expertise

Internal Medicine Director, Migraine

• Lead key activities to progress your career
• Be a recognized expert in the field of HIV (including treatment and prevention)
• Provide analyses and reviews of ViiV products, therapy areas, and competitor products
• Develop therapy area reviews, product monographs, slide sets, training packages, etc.
• Prepare and deliver presentations for sales force training programs

Regional Medical Director, Southeast

• 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

• Serve as a senior clinical leader and addiction medicine subject matter expert across the organization.
• Partner with Clinical Services leadership to strengthen clinical quality, consistency, and patient safety across Boulder’s care delivery model.
• Lead routine review and refinement of clinical protocols, formulary standards, and evidence-based practice guidelines.
• Support quality assurance activities, chart review processes, and clinical audits to identify opportunities for improvement.
• Provide consultation and guidance on complex clinical cases and emerging clinical issues.
• Ensure Boulder’s clinical standards remain aligned with current evidence, regulatory requirements, and payer expectations.
• Partner with Clinical Services leadership to strengthen clinical leadership capabilities across the organization.
• Provide mentorship, coaching, and support to clinical leaders and clinicians navigating complex clinical and operational challenges.
• Help establish and reinforce standards of clinical excellence, professional growth, and evidence-based practice.
• Contribute physician leadership and oversight to clinician education, onboarding standards, and ongoing clinical development programs.
• Support the development of systems that promote accountability, consistency, and continuous improvement across the clinical organization.
• Translate quality findings, operational priorities, and emerging evidence into scalable clinical workflows and care delivery standards.
• Identify gaps in clinical processes, policies, and infrastructure and partner across teams to implement solutions.
• Support implementation of new clinical initiatives and ensure clinical best practices are operationally viable and consistently applied.
• Drive adoption of new clinical workflows, protocols, and care models across a distributed clinical workforce.
• Partner with Medical Affairs and Clinical Services leadership to evaluate and support expansion into new service lines and care models.
• Assess clinical readiness, staffing considerations, protocol requirements, and quality implications for new programs.
• Ensure new services are designed with appropriate clinical governance, quality standards, and outcome measurement strategies.
• Contribute clinical expertise to Boulder’s long-term vision of comprehensive substance use disorder care.
• Serve as a clinical liaison to Product, Operations, Analytics, and other cross-functional teams.
• Translate clinical priorities into product requirements, workflows, and operational processes.
• Provide clinical input on care delivery technology, clinical decision support tools, AI-enabled workflows, and platform enhancements.
• Ensure operational and product changes are evaluated through the lens of patient safety, clinician experience, clinical effectiveness, and quality.

Medical Director – Addiction Medicine, Telehealth

• 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

Director, Rx Clinical Operations

• Provides administrative oversight to the medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on issues concerning medical policies
• Supports operations in the form of case review on both medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Provides input on issues and operational policies, processes, and procedures
• Educates staff and medical community on various aspects of medical policy and program administration
• Develops and updates medical policy in consultation with regulatory personnel, medical consultants, and professional societies
• Develops external relationships with the medical community and serves as liaison between these entities and the contractors
• Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization
• Conducts research into new or controversial medical procedures and technology

• Provides leadership and medical support on medical and regulatory matters.
• Identifies trends in medical and pharmacy costs, utilization trends, and proactively makes recommendations and initiates solutions to impact these.
• Provides leadership to clinical team and operations in order to increase compliance, improve efficiency, and increase communication.
• Acts as resource for providers, staff, part time medical reviewers, and as requested, customers, on issues concerning medical policies and regulations.
• Provides clinical support to Payment Integrity Unit(s) to analyze abuse patterns and recommend solutions.
• Provides oversight and leadership with quality improvement and health plan and medical program accreditation(s).
• Works with staff and other leadership in developing ideas related to quality initiatives, good clinical support, and outreach to the network.
• Responsible for physician review (UM, Appeals, CM) - reviews physician and provider practice pattern analysis and other statistical data.
• Conducts research into new or controversial medical procedures and technology.
• Educates staff, network providers, and medical community on various aspects of medical policy and program administration.

Behavioral Health Medical Director

• Provides administrative oversight to medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on medical policy issues
• Writes and revises medical policies
• Supports operations in case review on medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Provides input on issues and operational policies, processes, and procedures
• Educates staff and medical community on medical policy and program administration
• Develops and updates medical policies in consultation with regulatory personnel and consultants
• Develops external relationships with the medical community
• Reviews physician and provider practice pattern analysis and other statistical data
• Conducts research into new or controversial medical procedures and technology

• Responsible for assisting the Medical Director in the oversight of Utilization Management (UM) programs
• Support the development and maintenance of these programs, focusing on clinical accuracy and appropriateness
• Assist the Medical Director in developing strategic corporate direction for UM programs
• Support the SVP, Healthcare Services in preparing annual metrics of results for UM programs
• Contribute to measurable outcomes for prior authorization, step therapy, and quantity limit programs
• Collaborate with internal teams to support corporate HEDIS initiatives with appropriate clinical program development
• Work closely with clinical program development teams, clinical service operations, and clinical quality committees
• Provide clinical guidance and oversight to these areas
• Serve on IH committees as directed by the Medical Director

Associate Medical Director – UM PT

• Providing consultation and appropriate mortality assessment of complex medical files
• Interpreting laboratory and medical test results used to detect, diagnose, or monitor diseases that are seen in underwriting risk assessment
• Participating in the continuing education of the JH underwriting team
• Supporting research and development of manual updates with evidence-based research if needed

• 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, ensuring timely and quality decision making.
• 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 in accordance with regulatory, state, corporate, and accreditation requirements.
• Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
• 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, unusual provider practice patterns, and adequacy of benefit/payment components.
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
• 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.
• Represents the business unit at appropriate state committees and other ad hoc committees.
• May be required to work weekends and holidays in support of business operations, as needed.

• Bring knowledge and skills to the business of Blue Cross North Carolina
• Support value-based strategies and clinical operations
• Develop and drive strategy for varied Health Care initiatives
• Partner with internal and external clients to support agreements
• Evaluate and manage vendors to align with strategic direction
• Gather and analyze data for health outcomes improvement
• Represent BCNC through presentations and leadership

Medical Director jobs in South Carolina

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District Director of Clinical Services, RN

Assistant Regional Director, Clinical Services

Director, Internal Medicine – Field Medical Migraine

Physical Medicine and Rehabilitation Medical Director

Internal Medicine Director, Migraine

Regional Medical Director, Southeast

Director, Clinical Strategy – RPh

Medical Director – Addiction Medicine, Telehealth

Director, Rx Clinical Operations

Physical Medicine and Rehabilitation Medical Director

Behavioral Health Medical Director

Physical Medicine and Rehabilitation Medical Director

Associate Medical Director – UM PT

Medical Director

Medical Director

Associate Medical Director