Medical Director (Medical)

TL;DR

Medical Director (Medical Management): Reviewing escalated clinical cases to determine medical necessity and appropriateness with an accent on compliance with NCQA, URAC, CMS, and DOL regulations. Focus on conducting peer-to-peer discussions, advising multidisciplinary teams, and developing clinical protocols.

Location: Must be based in Pennsylvania (Working at Home options available)

Company

hirify.global is a major healthcare provider and insurer dedicated to clinical excellence and member care.

What you will do

• Conduct electronic reviews of escalated cases using medical policy criteria to determine medical necessity.
• Perform telephonic peer-to-peer discussions and compose detailed rationales for determination notifications.
• Collaborate with the multidisciplinary team (CMDM), participating in huddles and grand rounds.
• Develop clinical protocols and guidelines to ensure consistency across the review process.
• Serve as a physician subject matter expert for special projects aimed at improving member care.
• Ensure strict adherence to NCQA, URAC, CMS, DOH, and DOL regulatory standards.

Requirements

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) degree.
• Active medical state licensure (additional specific state licenses may be required).
• Board Certification in a specialty recognized by ABMS or AOA.
• At least 5 years of experience in clinical direct patient care.
• Minimum 1 year of experience in Medical Management within a Health Insurance Plan.
• Deep knowledge of the managed care industry and regulatory compliance.

Nice to have

• Master's Degree in Business Administration, Management, or Public Health.

Culture & Benefits

• Flexible work arrangement with "Working at Home" options for Pennsylvania residents.
• Collaborative environment working within a multidisciplinary clinical team.
• Opportunity to impact healthcare standards through protocol and guideline development.
• Professional environment focused on high clinical standards and regulatory excellence.