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

• 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

• 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

• 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

Medical Director jobs in West Virginia

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Medical Director – Part Time

Director, Clinical Strategy – RPh

Medical Director – Addiction Medicine, Telehealth

Regional Medical Scientific Director – Medical Science Liaison, Immunology

Senior Medical Director – Medicaid