Lead Medical Director (20 Hours Per Week)

The Lead Medical Director of UM has the responsibilities of supporting Health Services and Medical Services via utilization management activities including but not limited to prior authorization reviews, appeals, collaboration with requesting physicians, and post-service claim review. This role ensures that medical decisions align with evidence-based guidelines, regulatory requirements, and cost effective care strategies. The Lead Medical Director, collaborates with cross-functional teams, including pharmacy, claims, case management, and provider relations, to enhance patient outcomes while maintaining financial sustainability. This role will provide leadership to medical directors, oversee and participate in daily UM case reviews, peer to peer reviews and help resolve disputes related to denied claims or prior authorizations.

This role is a 0.5 FTE (20 hours per week).

Key Accountabilities:

• Utilization Management Oversight, Care Management and Appeals Decisions Participation

  • Review and approve medical policies, ensuring alignment with clinical best practices and regulatory standards.

  • Oversee utilization management, prior authorization processes, and medical necessity determinations.
  • Collaborate with claims and case management teams to evaluate complex medical cases.
  • Provide guidance on appeals, grievances, and dispute resolution regarding medical coverage.
  • Ensure compliance with federal and state healthcare regulations (e.g., CMS, NCQA, URAC).
  • Support provider engagement efforts by reviewing clinical guidelines and offering education.
  • Participate in quality improvement initiatives and data-driven healthcare strategies.
  • Work with actuarial and underwriting teams to assess cost and risk implications of medical policies.
• Committee Participation

  • Participates in the technology assessment committees and Policy Criteria Approval Committee (PCAC).

  • Participate as physician representative to other committees as needed.

• Administrative Oversight
  • Analyze utilization data and identify trends or areas for improvement.
  • Provide recommendations for process improvements to enhance efficiency and quality.
  • Provide ongoing education to ensure adherence to current clinical guidelines
  • Oversee and provide leadership to the medical directors, ensuring alignment with utilization management policies, clinical guidelines, and organizational goals.

Minimum Requirements:

• Doctor of Medicine (MD) or Doctor of Osteopathy (DO) degree from an accredited institution.
• 10 years experience as clinical provider; 3 years of health plan utilization management experience strongly preferred

Specific types of experience or skills required:

• Experience in health plan utilization management preferred.
• Strong knowledge of utilization review processes, medical necessity criteria (e.g., Milliman, InterQual), and healthcare regulations.
• Excellent communication, problem-solving, and decision-making skills.
• Maintain regularly assigned work schedule.
• Remote work

REQUIRED CERTIFICATIONS/LICENSURE: Must be a licensed physician with current Board certification of ABMS recognized specialty. Current medical license to practice must be without restrictions. Must be willing and able to apply for medical license in other states as needed.

This position is a Remote role and will work remotely 100% of the time. To be eligible for consideration, candidates must have a primary home address located within any state where Medica is registered as an employer - AR, AZ, FL, GA, IA, IL, KS, KY, MD, ME, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI.

The full salary range at 1.0 FTE for this position is $200,900 - $344,400. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Medica's commitment to diversity, equity and inclusion (DEI) includes unifying our workforce through learning and development, recruitment and retention. We consistently communicate the importance of DEI, celebrate achievements, and seek out community partnerships and diverse suppliers that are representative of everyone in our community. We are developing sustainable programs and investing time, talent and resources to ensure that we are living our values. We are an Equal Opportunity/Affirmative Action employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.