About The Role The Medical Director performs utilization review and medical necessity determinations for BHPS-administered self-funded commercial plans, and supports the Chief Medical Officer in maintaining the quality, consistency, and defensibility of the department’s clinical decisions. Clinical review is the core of the position; committee, education, and client-facing responsibilities are built around a standing review assignment.
- This is a Remote Role
- Renders medical necessity determinations across pre-service, concurrent, and post-service review within regulatory and contractual turnaround requirements
- Applies MCG care guidelines, client-specific criteria, and BHPS medical policy consistently, selecting the correct criteria source for the member’s plan and documenting rationale that is defensible on appeal, external review, and audit
- Conducts peer-to-peer discussions with attending and treating physicians regarding admissions, continued stay, level of care, site of service, and contested coverage decisions
- Reviews and adjudicates appeals for denied services in accordance with plan documents and applicable ERISA and state standards; does not serve as the ERISA appeals fiduciary
- Communicates certification and non-certification decisions to nurse reviewers within timeframes required by URAC, NCQA, ERISA, NYS Article 49, and other applicable state mandates
- Serves as clinical resource and escalation point for nurse reviewers on complex or criteria-silent cases, providing supporting clinical literature and written rationale
- Provides clinical input on member and provider grievances and reviews complaint resolution outcomes with the Grievance Coordinator
- Participates in long-length-of-stay rounds and complex case conferences with Case Management to align level-of-care decisions with the member’s clinical course and discharge plan
- Participates in the department’s inter-rater reliability testing, case audits, and reviewer calibration sessions, and supports consistent criteria application across reviewers and client books of business
- Assists in developing and maintaining medical policy, clinical review procedure, and the clinical content of the UM Program Description and annual program evaluation, in conjunction with the CMO
- Serves as a physician member of the Provider Credentialing Committee (PCC), Clinical Programs Quality Committee (CPQC), UM Committee, and Quality Committee as assigned
- Supports URAC and NCQA accreditation activity and client and health-plan delegation audits, including file review readiness and corrective action follow-through
- Delivers clinical education to physician and nurse reviewers, non-clinical staff, and network providers on criteria application, medical policy updates, and documentation expectations
- Represents Medical Management in client-facing meetings with self-funded employers, brokers, and health-plan partners, and responds to clinically escalated cases
- Serves as clinical subject-matter expert for Medical Management workflow and technology initiatives, including UM platform configuration and evaluation of clinical decision-support tools
- Maintains clinical currency through continuing medical education and maintenance of licensure and board certification
- Adheres to all BHPS policies and procedures and promotes a positive, collaborative work environment
- The Medical Director provides clinical mentorship and day-to-day guidance to nurse reviewers and intake staff, serves as a peer resource to other Medical Directors, and may be designated by the Chief Medical thOfficer to lead specific clinical quality, audit, or education initiatives
- MD or DO degree with active, unrestricted state medical licensure; New York licensure required or obtainable
- Current ABMS (or AOA equivalent) board certification, maintained throughout employment
- Minimum 5 years of post-training clinical practice in an office, hospital, or academic setting
- Minimum 2 years of utilization review or medical director experience at a health plan, TPA, managed care organization, or delegated medical group
- Hands-on experience applying MCG or comparable evidence-based criteria and writing adverse determination rationale
- Board certification in Internal Medicine or an Internal Medicine subspecialty
- Experience in a self-funded commercial or TPA environment
- Participation in a URAC or NCQA accreditation survey or client delegation audit
- CPE, MBA, MHA, or comparable physician-leadership or management credential
- Teaching, precepting, or curriculum development experience
- Working knowledge of URAC, NCQA, ERISA, CMS, and state utilization review and appeals regulation, including New York requirements
- Strong medical record review, evidence appraisal, and clinical policy interpretation skills
- Ability to write clear, member-readable determination rationale that withstands appeal and audit
- Sound, timely, independent clinical judgment under turnaround time pressure
- Effective verbal and written communication with physicians, staff, members, and client and broker audiences
- Proficiency with UM or EHR platforms and standard business software (Microsoft Office; reporting tools such as Excel or Tableau)
- Occasional travel for client meetings, provider engagement, and company or committee meetings
- Coverage of urgent and expedited review requests may be required outside standard business hours on a rotating basis
- We are an Equal Opportunity Employer
Medical Director in remote at Unknown Company
This position is listed as contract and able to be worked remotely.