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

• Directly handle high-exposure professional lines claims, including Allied Medical, Medical Professionals, Errors and Omissions, and Management Liability matters on both primary and excess policies
• Review claims and related systems and processes
• Understand and analyze policy language and contracts
• Provide coverage, liability, and damages analysis for claims and ensure timely reserving and appropriate legal and indemnity payments
• Develop and document claim strategy for complex professional liability matters, including regulatory, licensing, credentialing, standard-of-care, causation, damages, and consent-to-settle considerations where applicable
• Draft disclaimers and reservation of rights letters
• Negotiate settlements, mitigate losses, and control expenses
• Adhere to Claims Best Practices, Key Controls, and file handling requirements
• Maintain a high level of communication with leadership and underwriting partners
• Identify trends, emerging exposures, procedural improvements, and underwriting feedback from claim activity
• Present to management, support peer development, mentor new staff, and assist with organization-wide initiatives and improvement strategies for claims and business units
• Ensure appropriate reports are timely prepared and disseminated
• Ensure successful implementation of key organization-wide initiatives and improvement strategies for claims and our business units
• Support other functional groups within the organization
• Ensure compliance with internal corporate guidelines, processes and procedures
• Other duties as required by management
• Some travel, as required for trials & mediations, etc.

Claims Director, Professional Lines – Medical and Non-Medical

• Directly handle high-exposure professional lines claims, including Allied Medical, Medical Professionals, Errors and Omissions, and Management Liability matters on both primary and excess policies.
• Review claims and related systems and processes
• Understand and analyze policy language and contracts
• Provide coverage, liability, and damages analysis for claims and ensure timely reserving and appropriate legal and indemnity payments
• Develop and document claim strategy for complex professional liability matters, including regulatory, licensing, credentialing, standard-of-care, causation, damages, and consent-to-settle considerations where applicable.
• Draft disclaimers and reservation of rights letters
• Negotiate settlements, mitigate losses, and control expenses
• Adhere to Claims Best Practices, Key Controls, and file handling requirements
• Maintain a high level of communication with leadership and underwriting partners
• Identify trends, emerging exposures, procedural improvements, and underwriting feedback from claim activity.
• Present to management, support peer development, mentor new staff, and assist with organization-wide initiatives and improvement strategies for claims and business units.
• Ensure appropriate reports are timely prepared and disseminated
• Ensure successful implementation of key organization-wide initiatives and improvement strategies for claims and our business units
• Support other functional groups within the organization
• Ensure compliance with internal corporate guidelines, processes and procedures
• Other duties as required by management
• Some travel, as required for trials & mediations, etc

Senior Claims Director – Professional Lines, Medical and Non-Medical

• Lead a goal-oriented hospital housekeeping department to create a team environment that is effective, productive, and rewarding
• Provide leadership that supports a team environment that fosters morale, passion, quality, and respect
• Demonstrate continuous ability to maintain and/or improve customer and patient satisfaction
• Lead and manage team member recruiting, training, development, and assignments
• Perform daily inspections and assessments and coach and counsel team members
• Collaborate with department, facility, and company leadership to achieve goals
• Analyze data and make adjustments to meet facility, budget, and compliance goals
• Execute, maintain, and monitor quality control systems and budgets
• Drive compliance with health, safety, and industry regulatory agencies

Healthcare Housekeeping Executive Director

• 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

• support care management, quality, utilization management, credentialing, pharmacy, health policy implementation, technology assessment and risk management activities
• Completes care management case review for cases involving medical necessity review
• Completes appeal case review for cases involving medical necessity review
• Partners to establish priorities as appropriate for improving service at the point of care
• Completes quality of care complaint reviews for cases involving clinical aspects or clinical/service aspects
• Participates in rotation to above Committee Participation

Medical Director – Clinical Ops Case Review

• Own the design, implementation, and ongoing management of Mosaic’s clinical pharmacy care model.
• Ensure clinical services consistently deliver superior quality, including strong CMS Star Ratings and HEDIS measures, and lower total cost of care.
• Define the requirements for the technology that makes the clinical model effective, efficient, and scalable, and guide its procurement and development.
• Lead and grow the team of clinical pharmacists and pharmacy technicians, managing performance against key quality and outcome indicators.
• Determine staffing requirements and plan clinical staffing to meet patient and client demand while achieving financial goals.
• Partner with the Pharmacist-in-Charge and Legal and Regulatory to build and sustain a culture of compliance, and maintain patient medication records in line with regulatory requirements.
• Lead Quality Improvement Projects in collaboration with internal and external stakeholders.
• Work with senior Mosaic and RxAnte leaders and health plan clients to sell, deliver, and measure clinical outcomes.
• Supervise Mosaic’s preceptor program for pharmacy students completing APPE rotations, and convene a committee of clinical and scientific leaders.
• Represent Mosaic by presenting research and educational content at conferences and events.

Senior Director, Clinical Pharmacy Services

• Develops professional relationships and engages with national and regional SLs to ensure access to company-approved medical and scientific information on areas of therapeutic interest and Company products
• Conducts peer-to-peer scientific discussions and maintains a reliable presence with those SLs to ensure they have a medical contact within the company
• Addresses scientific questions and directs SL inquiries on issues outside of scope (e.g., grants) to appropriate company resources consistent with applicable policies
• Maintains current knowledge and comprehension of dynamic scientific and clinical environment in the Company's Areas of Interest (AOI) for your specific therapeutic area
• Initiates discussions with SLs and/or potential investigators that include scientific/data exchange within our AOI to determine the alignment with our research strategies, studies concepts, scientific merit, and qualifications for a specific compound or trial
• Recommends study sites and identifies potential investigators to participate in phase II-IV clinical development programs, conducts Site Initiation Visits (SIVs), and detects barriers to patient enrollment and retention efforts to achieve study milestones
• Engages in scientific congresses and medical meetings, facilitates scientific and data exchange for both Company and competitor data
• Gathers feedback, data, or information during routine activities that can help the company better comprehend medical or scientific needs, priorities, or concerns of SLs and/or patients

Regional Medical Scientific Director – Medical Science Liaison, Immunology

• responsible for the clinical integrity, safety, and sensitivity of a data collection effort measuring the effectiveness of mental health and suicide prevention services for the Veterans Health Administration (VHA).
• ensure that all operational protocols, staff training modules, and crisis escalations are executed with clinical empathy and adherence to VHA standards.
• oversee training of personnel in relevant mental health topics; development and compliance with crisis protocols; and clinical support for staff conducting interviews.
• design, implement, and enforce standardized operating procedures (SOPs) for identifying respondents in acute distress.
• oversee compliance with the standardized VHA protocol for connecting Veterans in crisis with the Veterans Crisis Line (VCL).
• conduct post-incident reviews of any crisis escalations to ensure protocols were followed correctly and to implement continuous improvement measures.
• develop and deliver training modules for all call center personnel focusing on mental health conditions (e.g., PTSD, depression, anxiety).
• provide real-time and scheduled clinical support to interviewers navigating difficult conversations.
• collaborate with the Contract Manager and Quality Assurance Team to review audio recordings of sensitive calls, providing clinical feedback and coaching.

Clinical Director – Part Time

• Supervise and support 4-6 Clinical Supervisors and counselors in service of enhancing clinical quality across the market.
• Partner closely with State Directors and cross departmental leads to steward the organization's mission and develop and meet clinical goals and objectives.
• Regularly provide clinical training to clinical supervisors and staff.
• Oversee the clinical supervision process and ensure standardization throughout the region.
• Coach clinical staff on managing complex cases, improving their independent, clinical skills and adhering to clinical policies and procedures
• Provide quality checks/audits and assure compliance with regulatory requirements.
• Assist with curriculum design and program development.
• Accountable for clinical outcomes and related KPIs in assigned region and for optimizing clinical KPIs.
• Cultivate a positive team environment where our mission and values come to life.
• Assist operational management to recruit 'A players' into every role, based on a deep understanding of the target profile and our values/culture (in collaboration with the State Director and Talent Acquisition team).
• Support employees' professional development through goal setting, coaching and feedback - and connect professional development to improved organizational performance.
• Ensure our policies and procedures are rigorously and consistently implemented.
• Address quarterly chart review trends and provide additional training/support, as needed, to ensure clinical documentation meets internal and external expectations
• Address feedback from members or other stakeholders.
• Help identify locations of where a Groups office, clinical model, and services would be successful while helping to identify key drivers that made those locations a key success.
• Build state and regional referral networks on Groups behalf, and connect Groups to key networks, other providers, insurers, and influencers.
• Evaluate and recommend alternative and experimental service models for operating in appropriate markets.
• Travel within your region as you evaluate local areas and consult with the wider leadership team.
• Keep the organization connected with appropriate circles such as county board meetings, advisory board meetings, etc., and represent Groups as a respected, positive presence in the community.
• Be an integral part of expansion in new states and markets working closely with State Directors.
• Ability to work remotely with regular and required travel to offices.
• Performs other duties as assigned.

Clinical Director

• 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 reviews with attending physicians or other providers to discuss review determinations
• 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

Medical Director – Physical Medicine and Rehabilitation

• Use your medical background, experience, and judgement to make determinations whether requested services, requested level of care, or requested site of service should be authorized, with all work occurring within a context of regulatory compliance and assisted by diverse resources
• Learn Medicaid requirements and understand how to operationalize this knowledge in your daily work assigned cluster
• Work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management
• Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations through the peer-to-peer process
• May speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities
• Supports Humana values including working collaboratively on a team throughout all activities
• Flows to work as needed within cluster as needed for vacations, weekends and holidays coverage.

Behavioral Health Medical Director, Medicaid

• Provides leadership of medical management activities in Aetna’s Northeast region (Maryland, New Jersey, New York, Pennsylvania, and Virginia)
• Lead a team of Medical Directors
• Collaborate with health plan chief medical officers
• Implement medical management programs/policies
• Direct the utilization review process and oversee the quality of utilization determinations

Senior Medical Director – Medicaid

• 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

• Provide oversight and support for psychotherapy clinicians
• Engage through coaching and education of new and tenured clinicians
• Enhance ongoing clinician professional growth and development
• Work in a dyad partnership with the Practice Group Manager
• Implement clinical strategy and related operations

• 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

Medical Director jobs in Virginia

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Medical Director – Part Time

Claims Director, Professional Lines – Medical and Non-Medical

Senior Claims Director – Professional Lines, Medical and Non-Medical

Healthcare Housekeeping Executive Director

Director, Clinical Strategy – RPh

Medical Director – Addiction Medicine, Telehealth

Director, Rx Clinical Operations

Medical Director – Clinical Ops Case Review

Senior Director, Clinical Pharmacy Services

Regional Medical Scientific Director – Medical Science Liaison, Immunology

Clinical Director – Part Time

Clinical Director

Medical Director – Physical Medicine and Rehabilitation

Behavioral Health Medical Director, Medicaid

Senior Medical Director – Medicaid

Behavioral Health Medical Director – Psychiatrist

Clinical Director

Medical Director – Oncology

Appeals Medical Director – Cardiology