What are the responsibilities and job description for the Medical Director (Utilization Management & Medical Review) position at Select Source International?
Position Title: Medical Director Utilization Management & Medical Review
Job Type: Contract-to-Perm (Temp-to-Perm)
Schedule: Monday Friday, 8:00 AM 5:00 PM EST (Minimal weekend call coverage, approx. once per month)
Location: Remote
Role Summary
We are seeking a hands-on, detail-oriented Medical Director to join our team in supporting expanded health plan operations, including state health plan and commercial lines of business.
This is an operational, "in-the-weeds" role focused on daily clinical decision-making, transactional case reviews, and peer-to-peer discussions. The ideal candidate thrives on direct clinical engagement, evaluating medical necessity, and ensuring compliance across Commercial, Medicare Advantage (MA), Federal Employee Program (FEP), and Appeals segments.
Key Responsibilities
Clinical Case Review & Utilization Management: Conduct daily medical necessity reviews, prior authorizations, and complex claims reviews across multiple lines of business (Commercial, Medicare Advantage, FEP, and State Health Plan).
Peer-to-Peer (P2P) Consultations: Engage directly with treating physicians and healthcare providers to discuss adverse determinations, medical necessity criteria, and coverage denials.
Appeals & Complex Determination: Evaluate complex suspended or disputed claims, reviewing benefit eligibility, medical records, and clinical guidelines to establish accurate liability and resolution.
Collaboration & Cross-Functional Support: Work with Internal Subject Matter Experts (SMEs), Provider Services, and Customer Service teams to resolve escalated cases and clarify coverage guidelines.
Fraud & Abuse Detection: Identify potential clinical quality issues, fraud, or abuse, escalating cases to the Special Investigations Unit (SIU) as necessary.
Process & System Efficiency: Identify technical or workflow bottlenecks, recommend enhancements to clinical review systems, and leverage continuous improvement to drive turnaround times.
Call Coverage: Participate in minimal weekend call rotation (approximately once per month).
Required Qualifications
Education: M.D. or D.O. degree from an accredited medical school.
Experience: 7 years of clinical practice and managed care / health insurance industry experience.
Core Expertise: Demonstrated, hands-on experience in Utilization Management (UM), peer-to-peer reviews, and clinical coverage determinations.
Market Knowledge: Background working within Commercial and Government health plan sectors (Medicare Advantage, FEP, or State/Public plans).
Technical Savvy: Comfortable navigating complex Health Plan Management Systems, VMS tools, EHR systems, and virtual collaboration software.
Preferred Qualifications
Licensure: Active, unrestricted North Carolina (NC) Medical License (or eligibility/willingness to obtain NC licensure).
Location: Candidates residing in North Carolina or nearby East Coast time zone states.
Job Type: Contract-to-Perm (Temp-to-Perm)
Schedule: Monday Friday, 8:00 AM 5:00 PM EST (Minimal weekend call coverage, approx. once per month)
Location: Remote
Role Summary
We are seeking a hands-on, detail-oriented Medical Director to join our team in supporting expanded health plan operations, including state health plan and commercial lines of business.
This is an operational, "in-the-weeds" role focused on daily clinical decision-making, transactional case reviews, and peer-to-peer discussions. The ideal candidate thrives on direct clinical engagement, evaluating medical necessity, and ensuring compliance across Commercial, Medicare Advantage (MA), Federal Employee Program (FEP), and Appeals segments.
Key Responsibilities
Clinical Case Review & Utilization Management: Conduct daily medical necessity reviews, prior authorizations, and complex claims reviews across multiple lines of business (Commercial, Medicare Advantage, FEP, and State Health Plan).
Peer-to-Peer (P2P) Consultations: Engage directly with treating physicians and healthcare providers to discuss adverse determinations, medical necessity criteria, and coverage denials.
Appeals & Complex Determination: Evaluate complex suspended or disputed claims, reviewing benefit eligibility, medical records, and clinical guidelines to establish accurate liability and resolution.
Collaboration & Cross-Functional Support: Work with Internal Subject Matter Experts (SMEs), Provider Services, and Customer Service teams to resolve escalated cases and clarify coverage guidelines.
Fraud & Abuse Detection: Identify potential clinical quality issues, fraud, or abuse, escalating cases to the Special Investigations Unit (SIU) as necessary.
Process & System Efficiency: Identify technical or workflow bottlenecks, recommend enhancements to clinical review systems, and leverage continuous improvement to drive turnaround times.
Call Coverage: Participate in minimal weekend call rotation (approximately once per month).
Required Qualifications
Education: M.D. or D.O. degree from an accredited medical school.
Experience: 7 years of clinical practice and managed care / health insurance industry experience.
Core Expertise: Demonstrated, hands-on experience in Utilization Management (UM), peer-to-peer reviews, and clinical coverage determinations.
Market Knowledge: Background working within Commercial and Government health plan sectors (Medicare Advantage, FEP, or State/Public plans).
Technical Savvy: Comfortable navigating complex Health Plan Management Systems, VMS tools, EHR systems, and virtual collaboration software.
Preferred Qualifications
Licensure: Active, unrestricted North Carolina (NC) Medical License (or eligibility/willingness to obtain NC licensure).
Location: Candidates residing in North Carolina or nearby East Coast time zone states.
Salary : $140 - $160