State Licensed Medical Director

Job Summary

Providing medical oversight and expertise, the full-time State Licensed Medical Director will evaluate the appropriateness and medical necessity of services for members, support utilization management programs, and participate in the appeals process while ensuring compliance with regulatory standards.

Key responsibilities

• Determines the appropriateness and medical necessity of health care services provided to plan members
• Supports the plan's utilization management program and monitors for over and under-utilization of services
• Participates in the appeals process and investigates adverse incidents and quality of care concerns

Required qualifications

• At least 3 years of health care experience, including 2 years of medical practice experience
• Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in the state of practice
• Board certification
• Working knowledge of applicable national, state, and local laws and regulatory requirements
• Ability to work cross-collaboratively within a highly matrixed organization