Impress employers and recruiters.
Choose from hundreds of resume examples.

Impress employers and recruiters.
Choose from hundreds of resume examples.

Target Resume Now

About the Role

The Medical Director will provide support to commercial and worker’s compensation self-funded clients for cost-effective claim resolution. This role involves leading and developing a team, maturing the program, and fostering a culture focused on service, quality healthcare, and medical cost containment.

Responsibilities

• Creates and updates medical policies and procedures, ensuring consistency and compliance with accepted medical standards.
• Provides clinical support across all Clinical Services areas.
• Reviews medical files and makes coverage and medical necessity determinations using guidelines.
• Identifies, critiques, and utilizes criteria and resources to support objective decision-making.
• Advises team nurses on care appropriateness across the continuum to ensure quality, cost-efficiency, and continuity.
• Informs the UR Nurse of certification decisions within regulatory timeframes.
• Supports training for nurses and coordinators to enhance their knowledge and independence.
• Serves as a medical expert for care management and population health, ensuring medical care meets acceptable standards.
• Reviews and resolves retro reviews, appeals, and grievances related to medical quality of care.
• Collaborates with supervisors and managers to identify improvement opportunities and enhance team performance.
• Conducts outreach to treating providers to discuss cases.
• Interacts with employees and departments to maintain effective communication and a positive work atmosphere.
• Interacts with sales and account management to support client needs.
• Collaborates with other departments to improve performance.
• Attends departmental committees as assigned.
• Performs other duties as required.
• Maintains proper credentialing, state licenses, and necessary certifications.

Requirements

• Board certified with an excellent understanding of utilization and case management processes.
• 3 years of experience in a managed care environment supporting utilization management and case review with medical necessity determinations.
• 3+ years of prior clinical practice in an office or hospital-based setting.
• Ability to stay up-to-date on a broad range of medical services using resources like MCG guidelines, specialty society guidelines, and Up-To-Date.
• Current, unrestricted clinical license(s).
• Board certification by American Board of Medical Specialties or American Board of Osteopathic Specialties, in Internal Medicine or Pediatrics or a subspecialty thereof, is required for MD or DO reviewer.
• Ability to communicate clearly and concisely, both verbally and in writing.
• Knowledge of evidence-based medical guidelines, utilization management, quality improvement, and other medical management functions.
• Good interpersonal and communication skills to support a team approach.
• Ability to work proficiently on a computer and knowledge of basic programs.

Skills

• Utilization management
• Case management
• Medical necessity determinations
• Population Health Management
• Evidence-based medical guidelines
• Quality improvement
• Medical management functions
• Interpersonal skills
• Communication skills
• Computer proficiency

Location

• Remote

Work Type

• Full-time

Experience Level

• 3 years experience in managed care
• 3+ years prior clinical practice

Education Level

• Board certified
• MD or DO reviewer

Salary/Compensations

• $200,000-$235,000 -bonus eligible

About the Company

• Brighton Health Plan Solutions, LLC is committed to improving healthcare access and delivery.
• The company fosters a diverse and welcoming culture focused on encouragement, respect, and increasing diversity, inclusion, and a sense of belonging.
• Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers, and other TPAs.
• They offer flexible and cutting-edge third-party administration services.
• Their unique perspective comes from decades of health plan management expertise, proprietary provider networks, and an innovative technology platform.
• As a healthcare enablement company, they provide customizable tools to enhance member experience, improve health outcomes, and achieve healthcare goals.
• Company Mission: Transform the health plan experience by bringing outstanding products and services to partners.
• Company Vision: Redefine health care quality and value by aligning partner incentives.
• DEI Purpose Statement: Encourage authentic selves at work, respect diverse experiences, and foster diversity, inclusion, and belonging.

Equal Opportunity

• We are an Equal Opportunity Employer