Medical Director, Medical Management

Location: Remote work from Pennsylvania, United States

Company

hirify.global provides health insurance and medical management services.

What you will do

• Review escalated cases against medical policy criteria to determine medical necessity and treatment appropriateness.
• Conduct initial determinations, appeals and grievance reviews, including telephonic peer-to-peer discussions when required.
• Prepare clear rationales for member and provider determination notifications.
• Advise the multidisciplinary case and disease management team, particularly on high-risk cases.
• Participate in protocol and guideline development, clinical huddles, grand rounds, and physician-led projects.
• Maintain compliance with NCQA, URAC, CMS, DOH, DOL, and applicable privacy and security requirements.

Requirements

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) degree.
• At least 5 years of clinical or direct patient care experience in a hospital, outpatient, or private-practice setting.
• At least 1 year of medical management experience in a health insurance plan and strong knowledge of managed care.
• Board certification in a specialty recognized by the American Board of Medical Specialties or American Osteopathic Association specialty certifying boards.
• Active medical state licensure; additional state licenses may be required based on business needs.
• Position is remote but limited to work from Pennsylvania, United States.

Nice to have

• Master's degree in business administration, management, or public health.

Culture & Benefits

• Remote work arrangement with an office-based position classification.
• Travel requirement of 0%–25%.
• Work includes collaboration with multidisciplinary clinical teams and participation in huddles and grand rounds.
• Responsibilities require compliance with HIPAA, privacy policies, information-security guidelines, and the company code of business conduct.