Medical Director of Utilization Management - Government Contracts

The Medical Director for Utilization Management with a focus on Government Contracts will oversee the clinical review process, ensuring that medical decisions for government-insured patients are consistent with regulations, evidence-based guidelines, and company policies. The role involves leading utilization management activities, collaborating with healthcare providers, and ensuring compliance with federal and state regulations, including Medicare and Medicaid requirements. In regard to Medica Government Segments, they will also serve as a clinical strategic liaison to workgroups and leadership for product development and optimization. The Medical Director will play a key role in improving clinical outcomes, controlling cost, and ensuring that care is medically necessary and appropriate for the populations covered by government health programs.

Key Accountabilities

• Utilization Management Oversight, Care Management and Appeals Decisions Participation
• Reimbursement Policies for Clinical Services
• Regulatory Compliance and Government Contracts
• Education and Provider Engagement
• Committee Participation

Qualifications

• 10+ years as clinical practice in a relevant medical specialty (e.g., family medicine, internal medicine)
• 3+ years of experience in utilization management or medical director roles within the healthcare insurance industry, preferably working with government contracts (Medicare, Medicaid)
• Medical Doctorate (MD) or Doctor of Osteopathic Medicine (DO) degree preferred
• Strong understanding of CMS regulations Medicare and Medicaid guidelines, and other government contract requirements. In-depth knowledge of utilization management, medical necessity criteria (e.g., Milliman Care Guidelines), and evidence-based medicine

Required Certifications/Licensure

• 
  

  Must be a licensed physician with current Board certification of ABMS recognized specialty. Current medical license to practice must be without restrictions. Must be willing and able to successfully apply for medical license in Minnesota and other states as needed.

  
  

Skills and Abilities

• Experience with quality improvement initiatives, medical policy development, and provider engagement.
• Experience in a managed care setting, particularly working with government-sponsored healthcare plans.
• Experience in health plan utilization management preferred.
• Strong ethical and professional integrity
• Ability to work collaboratively in a fast-paced environment with diverse stakeholders.
• High attention to detail with a commitment to accuracy in clinical decision-making

This position is a Remote role and will work remotely 100% of the time. To be eligible for consideration, candidates must have a primary home address located within any state where Medica is registered as an employer - AR, AZ, FL, GA, IA, IL, KS, KY, MD, ME, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI.

The full salary range for this position is $196,000 - $336,000. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Medica's commitment to diversity, equity and inclusion (DEI) includes unifying our workforce through learning and development, recruitment and retention. We consistently communicate the importance of DEI, celebrate achievements, and seek out community partnerships and diverse suppliers that are representative of everyone in our community. We are developing sustainable programs and investing time, talent and resources to ensure that we are living our values. We are an Equal Opportunity/Affirmative Action employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.