About The Role The Medical Director will be responsible in providing support to our commercial and worker’s compensation self-funded clients seeking cost effective resolution of their member’s claims. Your interest and help leading and developing our team and maturing the program only makes the opportunity more rewarding.   We have been in business for 25 years and leading by example you will help create a culture focused on service, support of quality healthcare service, and medical cost containment for the benefit of our clients and their members. Primary Responsibilities + Creates and updates medical policies and procedures in conjunction with associate medical directors and other clinical staff and assures consistency and compliance with generally accepted medical standards and guidelines. + Provides clinical support for all areas of Clinical Services. + Review medical files and make coverage and medical necessity determinations using good judgement combined with 3rd party and proprietary medical guidelines.  + Identify, critique, and utilize criteria and resources such as national, state, and professional association guidelines and peer reviewed literature to support sound and objective decision making and rationales in reviews. + Advises team nurses on appropriateness of care and services through the care continuum including hospitals, skilled nursing facilities, and home care to ensure quality, cost-efficiency and continuity of care; Informs the UR Nurse of certification decisions within appropriate time frames as guided by URAC, ERISA or state regulations. + Supports training of the nurses and coordinator to improve their knowledge, independence, and understanding. + Serves as medical expert for care management and population health; reviews and evaluates cases with review nurses; ensures medical care provided meets the standards for acceptable medical care. + Reviews and resolves retro reviews, appeals and grievances related to medical quality of care and actively participates in the functioning of the plan’s grievance and appeals processes. + Along with the nurse supervisor and manager identify opportunities for improvement and collaborate to enhance team performance.  + Makes appropriate outreach to community and academic based treating providers wanting to discuss cases. + Interacts telephonically and personally with employees/departments in order to maintain effective communication and support for and among departments, as well as a positive work atmosphere. + Opportunity to interact with sales and account management supporting client needs. + Collaborates with other departments i.e. Member Services, Provider Services, Claims and Contracting, to improve performance. + Attends departmental committees as assigned. + Performs other duties as required by the business. + Maintain proper credentialing and state licenses and any special certifications or requirements necessary to perform the job. Essential Qualifications + Board certified with an excellent understanding of the utilization and case management process. + 3 years’ experience working in a managed care environment supporting utilization management and case review with medical necessity determinations. + Case management and / or Population Health Management desirable. + 3 + years of prior clinical practice in either an office or hospital-based setting with boards from any of a wide range of Internal Medicine specialties so long as you are self-motivated to stay up to date on a broad range of medical services using resources such as mcg guidelines, specialty society guidelines, Up-To-Date and other resources to analyze existing cases. + Specialty training in addition to a first board certification highly desirable. + Current, unrestricted clinical license(s). + Board certification by American Board of Medical specialties or American Board of Osteopathic Specialties, in Internal Medicine or Pediatrics or a subspecialty of Internal Medicine or Pediatrics, is required for MD or DO reviewer. + Ability to communicate clearly and concisely, both verbally and in writing. + Knowledge of evidence-based medical guidelines (nationally recognized standards of health care), utilization management, quality improvement and other medical management functions. + Good interpersonal and communication skills to support the team approach. + Ability to work proficiently on a computer and knowledge of basic programs. About At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities. Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes, and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions. Come be a part of the Brightest Ideas in Healthcare™. Company Mission Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners. Company Vision Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways. DEI Purpose Statement  At BHPS, we encourage all team members to bring your authentic selves to work with all your unique abilities.   We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace.  We are building, nurturing, and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level. Annual Salary Range: $200,000-$235,000 -bonus eligible The salary range and/or hourly rate listed is a good faith determination that may be offered to a successful applicant for this position at the time of the posting of an advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable by law including but not limited to location, years of relevant experience, education, credentials, skills, budget and internal equity. *We are an Equal Opportunity Employer JOB ALERT FRAUD:  We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information.  Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section.  If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: recruiting@brightonhps.com Powered by JazzHR