Wisconsin Licensed Medical Director

Job Summary

Offering a temporary remote opportunity, the Wisconsin Licensed Medical Director will oversee utilization management activities, participate in clinical decision-making, and render denial determinations for services deemed not medically necessary, with a workload of reviewing approximately 5 to 10 appeals daily.

Key responsibilities:

• Assist the Chief Medical Officer by monitoring care appropriateness and provider participation
• Participate in oversight and clinical decision-making of the utilization management program
• Render denial decisions for services that do not meet medical necessity standards or are investigational

Required qualifications:

• Doctor of Medicine or Doctor of Osteopathic Medicine licensed in Wisconsin without restrictions
• 7+ years of experience in medical utilization review or related clinical fields
• Experience working with multiple lines of business: Medicare Advantage, commercial insurance, and ACA
• Proficiency in systems/software, particularly MS Teams and MS Office suite
• Strong understanding of regulatory standards governing healthcare and utilization management