Medical Director
Not Disclosed•ContractorRemote
location_onLogan Street, Downtown, Pittsburgh, Allegheny County, Pennsylvania, 15262, United States
About the Role
As a Medical Director – Utilization Management, you will serve as a pivotal physician leader within a remote team, ensuring that all utilization management activities align with the highest and most current clinical standards. This role is designed to bridge the gap between clinical expertise and operational efficiency, focusing on the rigorous review of escalated cases to determine the medical necessity and appropriateness of requested treatments.
In this position, you will not only conduct electronic reviews against established medical policy criteria but also engage in telephonic peer-to-peer discussions when necessary. Beyond individual case reviews, you will act as a key advisor on high-risk and complex cases, participating as a physician member of a multidisciplinary team dedicated to case and disease management. Your insights will help guide protocol and guideline development, ensuring consistency in the review process and supporting special projects aimed at improving member care.
Team Context
You will be joining a physician team that operates with a strong commitment to compliance and quality. The team navigates a complex regulatory landscape, ensuring adherence to NCQA, URAC, CMS, DOH, and DOL regulations at all times. This role requires a unique blend of clinical acumen and managed care knowledge, specifically within a payer-side health insurance environment. While hospital-side experience is valuable, the core of this position demands familiarity with the specific dynamics of utilization management within an insurance context.
Application Instructions
Preference will be given to candidates who bring direct payer-side Utilization Management experience within a health insurance environment. Candidates with only hospital-side UM experience may not meet the specific requirements of this contract role. Interested physicians should ensure they possess the necessary state licensure for PA, NY, or WV and are prepared for a high-volume productivity expectation of 55+ cases completed in an 8-hour day.
Work location
Work model: Remote
Logan Street, Downtown, Pittsburgh, Allegheny County, Pennsylvania, 15262, United States
Pittsburgh, Pennsylvania
Key Responsibilities
- check_circleConduct electronic review of escalated cases against medical policy criteria to determine medical necessity
- check_circleComplete initial determinations, appeals, grievances, and other reviews as assigned
- check_circleCompose clear rationales for provider and member determination notifications while adhering to compliance standards
- check_circleParticipate as a physician member of a multidisciplinary team for case and disease management
- check_circleAdvise multidisciplinary teams on high-risk and complex cases requiring physician expertise
- check_circleParticipate in protocol and guideline development to ensure consistency in the review process
- check_circleManage projects or participate on project teams requiring physician subject matter expertise
Requirements
- verifiedMedical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
- verifiedMinimum 5 years of direct patient care experience
- verifiedBoard Certification in a specialty recognized by ABMS or AOA
- verifiedActive medical state licensure for PA, NY, or WV
- verifiedCase management experience
- verifiedManaged care experience
- verifiedMaster's Degree in Business Administration/Management or Public Health (Preferred)
- verifiedMinimum 1 year of Medical Management experience within a Health Insurance Plan (Preferred)
- verifiedExperience with MCG or InterQual (Preferred)
Nice to Have
Master's Degree in Business Administration/Management or Public Health. Minimum 1 year of Medical Management experience within a Health Insurance Plan. Strong knowledge of the managed care industry. Experience with MCG or InterQual.
Similar Job Opportunities
Skills, education and keywords
Skills: Utilization Management, Case Management, Managed Care, Medical Policy, Ncqa, Urac, CMS, MCG, Interqual.
Education: Master's Degree in Business Administration/Management or Public Health preferred.
Frequently asked questions about Medical Director at TPI Global Solutions
What does a Medical Director at TPI Global Solutions do?expand_more
In this Medical Director at TPI Global Solutions role, you will conduct electronic review of escalated cases against medical policy criteria to determine medical necessity; complete initial determinations, appeals, grievances, and other reviews as assigned; compose clear rationales for provider and member determination notifications while adhering to compliance standards; and participate as a physician member of a multidisciplinary team for case and disease management.
What are the requirements for this Medical Director role?expand_more
To qualify for the Medical Director at TPI Global Solutions position, applicants should have: Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO); Minimum 5 years of direct patient care experience; Board Certification in a specialty recognized by ABMS or AOA; Active medical state licensure for PA, NY, or WV; Case management experience; and Managed care experience.
Where is the Medical Director role at TPI Global Solutions located?expand_more
Medical Director at TPI Global Solutions is based in Logan Street, Downtown, Pittsburgh, Allegheny County, Pennsylvania, 15262, United States. This is a remote role.
Is this Medical Director job remote, hybrid, or on-site?expand_more
TPI Global Solutions has listed this Medical Director role as remote.
How much experience is required for this Medical Director role?expand_more
Medical Director at TPI Global Solutions typically requires 5+ years of relevant experience at the executive level.
What skills do you need for the Medical Director role at TPI Global Solutions?expand_more
Key skills for Medical Director at TPI Global Solutions include Utilization Management; Case Management; Managed Care; Medical Policy; Ncqa; Urac; CMS; and MCG.
What education is required for Medical Director at TPI Global Solutions?expand_more
Educational requirements for this role: Master's Degree in Business Administration/Management or Public Health preferred.
What category does the Medical Director role belong to?expand_more
Medical Director at TPI Global Solutions is part of the healthcare & nursing job category on Recrutus.