Charleston, SC

The Medical Director will provide organizational leadership in the operational areas of utilization review, case management, quality improvement and related policy and practice initiatives.The candidate will serve as the lead physician for the Plan working closely with other medical management team members

  • Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
  • Utilizes the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
  • Participates in provider network development and new market expansion as appropriate.
  • Assists in the development and implementation of physician education with respect to clinical issues and policies.
  • Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
  • Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.

Requirements

  • MD
  • Must be licensed to practice in the state.
  • Must be Board-certified in his/her medical specialty.
  • Must be clear of any sanctions by the applicable state or Office of the Inspector General.
  • Must not be prohibited from participating in any Federally or State funded healthcare programs.
  • Full-time experience as an administrator in a Medicare or state-level Medicaid program, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), large Health Care Organization, health plan or any combination thereof.
  • 8+ years’ experience in senior management and or Medical Director experience; 7 years Utilization Review and Case management experience.
  • 5+ years of medical management and general management experience in a managed care environment is preferred.
  • Primary care discipline, prior experience as Associate Medical Director (or equivalent) or physician reviewer in a Managed Care Plan preferred.
  • Utilization management experience preferred. Minimum five years of progressive business experience.

Apply Now

Not sure if you want to apply?
Contact us for more info:
Rebecka Boyd
804-502-0870
nexusexecutivesearch@gmail.com