Chief Medical Director

We are seeking an experienced physician leader to serve as Chief Medical Director, providing clinical oversight and strategic leadership for medical necessity reviews and utilization management programs. This executive role is responsible for ensuring high-quality, evidence-based clinical decision-making while supporting operational excellence, regulatory compliance, and collaboration across multidisciplinary teams.

The ideal candidate brings extensive experience in Medicare and Medicaid medical management, physician leadership, and healthcare operations, with the ability to balance clinical expertise, regulatory requirements, and organizational priorities.

Key Responsibilities

Clinical Leadership

• Lead and mentor a team of Medical Directors responsible for utilization management, appeals, and medical necessity reviews.
• Provide coaching, education, and professional development opportunities to physician leaders.
• Foster a collaborative, high-performing clinical culture focused on quality, accountability, and continuous improvement.
• Partner with executive leadership to align clinical operations with organizational goals.

Medical Necessity Reviews

• Perform medical necessity reviews and appeals as needed.
• Evaluate requests involving:
• Home Health
• Skilled Nursing Facilities
• Durable Medical Equipment (DME)
• Home- and community-based healthcare services
• Apply sound clinical judgment using nationally recognized evidence-based guidelines and regulatory requirements.
• Address complex clinical and operational issues while ensuring fair, consistent, and timely decisions.

Regulatory Compliance

• Ensure compliance with CMS regulations, Medicare and Medicaid requirements, and applicable federal and state laws.
• Maintain consistency, accuracy, and timeliness in clinical review processes.
• Support organizational quality and performance initiatives related to utilization management and medical review.

Cross-Functional Collaboration

• Serve as a trusted clinical advisor to operational, compliance, and executive leadership teams.
• Collaborate with internal stakeholders to improve workflows, resolve clinical issues, and enhance service delivery.
• Participate in strategic initiatives that improve member outcomes and operational effectiveness.

Operational Excellence

• Identify opportunities to improve clinical workflows and utilization management processes.
• Analyze operational and clinical data to identify trends, risks, and opportunities for improvement.
• Support process standardization, technology adoption, and performance optimization.

Education & Communication

• Develop and deliver educational programs for physicians and clinical staff.
• Clearly communicate clinical guidelines and regulatory requirements to internal stakeholders.
• Participate in clinical conferences, leadership meetings, and quality improvement initiatives.

Qualifications

Required

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• Current board certification through an ABMS-recognized specialty.
• Active, unrestricted medical license with the ability to obtain additional state licenses as needed.
• Minimum of:
  • 5 years of post-residency or fellowship clinical practice.
  • 2 years of physician leadership experience.

Strong knowledge of:

• Medicare
• Medicaid
• Utilization Management
• Medical Necessity Determinations
• CMS regulations
• Experience applying nationally recognized clinical guidelines (e.g., MCG®, InterQual®, LCD/NCD).
• Excellent analytical, leadership, communication, and decision-making skills.

Preferred

• Previous experience in health plan medical management or payer-based clinical leadership.
• Experience collaborating with hospitals, physician organizations, and healthcare providers.
• Board certification in Internal Medicine, Family Medicine, Geriatrics, Hospital Medicine, or a related specialty.
• Experience serving Medicare, Medicaid, or Dual Eligible populations.

Work Environment

• Remote position with occasional travel for meetings, leadership sessions, or organizational events.
• Flexibility to provide limited evening, weekend, or holiday coverage when operationally necessary.

Compensation & Benefits

A competitive compensation package will be offered and is commensurate with experience and qualifications. A comprehensive benefits package, retirement savings plan, paid time off, and professional development opportunities are included.

Equal Opportunity Employer

We are committed to creating an inclusive workplace and are proud to be an Equal Opportunity Employer. Employment decisions are based on qualifications, merit, and business needs without regard to any protected status under applicable federal, state, or local laws.