Medical Director

Medical Director Remote

We are seeking an experienced and dedicated Medical Director to oversee daily clinical operations and administration of a Medical Management Department. This role ensures the delivery of quality medical care, regulatory compliance, and effective utilization management while supporting organizational goals.

Key Responsibilities

• Utilization Management (50%) Manage medical resource use for inpatient and outpatient services, determine medical appropriateness using clinical criteria, conduct case management reviews, issue clinical determinations, and participate in appeals processes.
• Policy & Process Oversight (10%) Develop, implement, and validate policies, workflows, and operational processes to support strategic goals. Monitor adherence and lead improvement initiatives.
• Department Leadership (10%) Develop annual departmental goals and provide oversight of assigned functions.
• Stakeholder Communication (10%) Support Senior Medical Directors with internal and external communications, ensuring high levels of satisfaction among members, providers, vendors, and regulatory bodies.
• Problem-Solving & Analysis (10%) Identify trends, conduct root cause analysis, and implement solutions to improve operational efficiency. Participate in contract negotiations and interdepartmental committees.
• Committee Participation (5%) Chair or serve on committees as assigned.
• Other Duties (5%) Perform additional responsibilities as required.

Qualifications:

Education & Licensure:

• MD or DO degree (required)
• Board Certification (required)
• Active New York medical license, unrestricted (required)

Experience & Skills:

• Minimum 5 years of clinical practice (required)
• Administrative/leadership experience in a hospital, medical group, or insurance setting (preferred)
• Strong knowledge of clinical medicine, healthcare delivery systems, utilization management, and treatment protocols (required)
• Understanding of managed care principles, physician reimbursement, and regulatory standards (required)
• Excellent communication, decision-making, and leadership skills (required)

Compliance & Standards:

This role requires ensuring compliance with Department of Health, Department of Insurance, CMS, NCQA, and URAC standards.

We are an equal opportunity employer and prohibit discrimination/harassment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.