Medical Director- Florida Medicare

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Prefer candidates that live near a location in Florida. Alternate locations may be considered.  

The Medical Director is responsible for utilization management, medical necessity clinical reviews of both inpatient and outpatient authorizations, appeals medical necessity reviews, and peer to peer clinical discussions. Additionally, responsibilities will include active participation in assigned committees such as peer review committee, credentialing committee, quality committees, etc. This medical director may be asked to participate in cost of care initiatives and lead projects assigned. This role requires weekend on call expectations given UM requirements and turnaround time compliance standards as set by Medicare.

How you will make an impact:

• Supports clinicians to ensure timely and consistent responses to members and providers.
• Provides guidance for clinical operational aspects of a program.
• Perform utilization management reviews to determine medical necessity and appropriateness of care, using nationally recognized criteria (e.g., MCG, InterQual, CMS guidelines).
• Collaborate with UM nurses and case managers to review inpatient admissions, outpatient procedures, and continued stays.
• Provide peer-to-peer discussions with treating physicians to discuss medical necessity decisions and care alternatives.
• Ensure timely and accurate completion of reviews in compliance with state and federal regulations, NCQA, and company standards.
• Serves as a resource and consultant to other areas of the company.
• May be required to represent the company to external entities and/or serve on internal and/or external committees.
• May chair company committees.
• Interprets medical policies and clinical guidelines.
• May develop and propose new medical policies based on changes in healthcare.
• Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes.
• Identifies and develops opportunities for innovation to increase effectiveness and quality.
• Expectation for this role also includes weekend and holiday coverage during assigned weekend rotations to support continuity of UM operations and ensure timely case processing.

Minimum Requirements:

• Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
• Must possess an active unrestricted medical license to practice medicine or a health profession in Florida.
• Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US.
• Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
• For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required. Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency.

Preferred Qualifications:

• Previous Medicare experience preferred.
• Internal/Family Medicine or other adult medicine training preferred.