Employment Type: 12-Month Contract (Potential for Conversion)
We are seeking an experienced Medical Director to join a leading healthcare organization supporting Commercial, Medicare Advantage, Federal Employee Program (FEP), and Appeals lines of business. This role is ideal for a physician with strong utilization management and health plan/payer experience who enjoys collaborating with providers and making evidence-based clinical decisions.
Key Responsibilities
- Perform utilization management reviews across multiple lines of business.
- Conduct peer-to-peer discussions with treating providers regarding coverage determinations and medical necessity.
- Review prior authorizations, appeals, and medical policy cases.
- Provide clinical guidance to internal business partners and cross-functional teams.
- Analyze clinical data to support quality improvement and operational initiatives.
- Partner with providers and healthcare stakeholders to improve clinical outcomes and member experience.
- Contribute to medical policy development and strategic healthcare initiatives.
- Participate in an on-call rotation (minimal weekend coverage).
Required Qualifications
- MD or DO from an accredited medical school.
- Completion of an accredited residency program.
- Active North Carolina medical license required.
- Board Certification in an ABMS- or AOA-recognized specialty.
- Minimum of 7 years of relevant clinical experience.
- Previous experience in Utilization Management within a health plan, managed care organization, or payer environment.
- Experience reviewing Commercial, Medicare Advantage, and Appeals cases.
- Strong clinical judgment, communication, and provider collaboration skills.
- Comfortable working in a fast-paced, technology-driven environment.
Preferred Qualifications
- Experience supporting both government and commercial health plans.
- Prior Medical Director or physician advisor experience.
- Experience with medical policy and evidence-based coverage determinations.