Medical Director

About the Role

We're looking for an experienced, dynamic Medical Director to lead our clinical operations in TX, FL, NY, IL, and NJ. In this key executive role, you will bridge the gap between clinical practice and administrative management, ensuring the delivery of high-quality, cost-effective care while maintaining compliance with state and federal regulations.

The Medical Director will collaborate with interdisciplinary teams, oversee utilization management programs, develop clinical policies, and serve as the primary medical liaison with providers, regulatory bodies, and community partners. This position offers the opportunity to shape clinical practice within a mission-driven organization committed to excellence and innovation in healthcare.

Key Responsibilities

Clinical Leadership & Oversight

• Provide clinical leadership and guidance to physicians, nurse practitioners, and other healthcare professionals across the multi-state footprint.

• Oversee the development, implementation, and continuous improvement of clinical protocols, policies, and procedures to ensure evidence-based, patient-centered care.

• Serve as the primary medical expert and liaison between administration, medical staff, and external stakeholders.

• Provide medical supervision and support to clinical staff on complex cases, quality of care concerns, and medical necessity determinations.

Utilization Management & Quality Improvement

• Lead and oversee Utilization Management (UM) programs, including prior authorization, concurrent review, and appeals processes.

• Ensure timely and consistent medical necessity determinations for inpatient and outpatient services, acute and post-acute care, and pharmacy benefits.

• Participate in or chair committees related to quality improvement, credentialing, pharmacy and therapeutics (P&T), and peer review.

• Monitor and evaluate healthcare outcomes using data analytics to identify areas for improvement and implement corrective actions.

• Facilitate compliance with NCQA, HEDIS, Medicare, Medicaid, and other regulatory and accreditation standards.

Regulatory Compliance & Policy Development

• Ensure all medical activities comply with applicable state and federal healthcare laws and regulations, including HIPAA, ACA, and state-specific scope of practice requirements.

• Develop, review, and amend medical policies to reflect current standards of care and regulatory requirements .

• Participate in regulatory audits, surveys, and state fair hearings as the medical representative.

• Maintain working knowledge of each state's specific healthcare landscape, including managed care regulations and Medicaid/Medicare requirements in TX, FL, NY, IL, and NJ.

Provider Relations & Stakeholder Engagement

• Educate and interact with network providers, group practices, and medical managers regarding utilization practices, guideline usage, and effective resource management.

• Foster strong relationships with community organizations, hospitals, and healthcare providers to enhance coordinated care delivery.

• Act as the primary medical contact for hospital admissions, emergencies, and urgent care coordination.

• Participate in educational outreach, professional conferences, and community activities to represent the organization.

Strategic Planning & Administrative Leadership

• Collaborate with executive leadership to develop strategic plans, goals, and objectives for the medical department.

• Assist in financial planning and budgeting as it pertains to medical operations, resource allocation, and cost management.

• Participate in the recruitment, selection, training, and evaluation of clinical staff.

• Participate in a rotating on-call schedule for weekend and holiday coverage as needed.

Qualifications & Requirements

Education & Licensure

• Medical Degree (MD or DO) from an accredited institution.

• Current, unrestricted medical license to practice in at least one of the following states: TX, FL, NY, IL, or NJ. Ability to obtain additional state licenses as required.

• Current and active Board Certification in an ABMS or AOA recognized specialty (Family Medicine, Internal Medicine, Pediatrics, or other primary care specialty preferred).

• Valid and current DEA registration.

Experience

• Minimum of 5 years of clinical experience in a healthcare delivery system (clinical practice, hospital, or health plan setting).

• At least 2-3 years of experience in a leadership or managerial role, such as Medical Director, Associate Medical Director, or Physician Advisor.

• Preferred: Experience in managed care, Medicaid/Medicare plans, or health plan/utilization management.

• Preferred: Experience with NCQA, HEDIS, quality improvement initiatives, and evidence-based guideline implementation.

Skills & Competencies

• Strong leadership, consensus-building, and collaborative abilities.

• Excellent verbal and written communication skills for interactions with diverse stakeholders.

• Deep knowledge of healthcare laws, regulations, and accreditation standards (state and federal)

• Proficiency in data analytics, quality improvement methodologies, and electronic health records (EHRs).

• Strategic thinking and problem-solving skills with the ability to make data-driven decisions.

• Ability to manage multiple priorities in a fast-paced, highly regulated environment.