Job Title: Medical Director
Specialty: Internal Medicine or Geriatrics
Schedule: 32–40 hours per week
Work Arrangement: 100% Remote / Virtual
License Requirement: Active, unrestricted New York medical license required

The Medical Director is responsible for overseeing the administration of physical and/or behavioral health medical services to ensure members receive appropriate, evidence-based, and cost-effective care. This physician leader may also support program development, medical policy interpretation, quality improvement initiatives, and clinical strategy designed to improve healthcare quality, outcomes, and cost performance.

Position summary

This role serves as a clinical resource and strategic advisor to support utilization management operations, peer-to-peer reviews, appeals, and broader medical management initiatives. The Medical Director works independently with oversight from leadership and may provide direction to clinical staff, including Medical Director Associates, while helping ensure timely and consistent determinations for members and providers.

Key responsibilities

• Conduct peer-to-peer clinical reviews with attending physicians and other providers to discuss medical necessity determinations, treatment plans, and requested services.

• Review clinical appeal cases and discuss determinations with attending or ordering providers as needed.

• Interpret medical policies, clinical guidelines, and benefit language to support consistent and appropriate utilization decisions.

• Provide clinical consultation and strategic guidance to enhance utilization management and broader clinical operations.

• Support clinicians in delivering timely, consistent responses to providers and members and serve as a resource to internal teams.

• Help identify cost-of-care opportunities and contribute to programs that improve quality, affordability, and outcomes.

• Lead, develop, and implement clinical and non-clinical activities that impact health care quality, cost, and utilization.

• May support or oversee an entire clinical program, including policy development, program implementation, and operational improvement efforts.

• Represent the organization to external stakeholders and participate in internal and external committees as needed.

• Educate providers and internal partners on medical policy, clinical guidelines, and managed care principles as appropriate.

Qualifications

• MD or DO required, with board certification through an ABMS- or AOA-approved board, where applicable to the duties performed.

• Board certification in Internal Medicine or Geriatrics strongly preferred based on the clinical focus of the role.

• Active, unrestricted New York medical license required.

• Minimum of 10 years of clinical experience required.

• Prior utilization management experience strongly preferred.

• Strong oral, written, interpersonal, analytical, facilitation, and problem-solving skills required.

• Must be able to work remotely from within the United States when conducting utilization review or appeals activities, consistent with regulatory requirements.

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