Lead Medical Director

Job Description

The Lead Medical Director will collaborate closely with the Senior Medical Director and team to oversee administrative and utilization management (UM) services. This role involves conducting various UM reviews, including Pre-service, Post-service, Concurrent Review, and Appeals. The Lead Medical Director will ensure adherence to health plan policies, clinical guidelines, and regulatory requirements to make timely decisions on medical necessity requests.

Additionally, this position involves mentoring other Medical Directors and supporting/leading quality initiatives, credentialing activities, and policy development. The Lead Medical Director will support, as needed, the VP(s) of Health Services. This will include managing member/provider escalations, interfacing with Network physicians/groups, monitoring departmental performance, and focusing on improved quality, cost, and satisfaction for our members and providers.

Job Duties Include But Are Not Limited To

• Conduct all types of utilization management (UM) reviews, including Pre-service, Post-service, Concurrent Review, and Appeals
• Conduct peer-to-peer discussions with physician providers
• Apply health plan review hierarchy to member contracts, medical policy, and clinical guidelines to render decisions on medical necessity
• Collaborate with Case Managers to offer physician assistance on complex cases
• Meet established metrics for UM review efficiency, timeliness, and quality
• Participate in Inter-rater reliability (IRR) audits and health plan audits as required
• Assist nurses and staff in understanding utilization review principles and benefit interpretation
• Contribute to the development and review of Medical and Pharmacy policies
• Serve as a subject matter expert within the organization
• Act as lead consultant for a designated sub-category of utilization management (e.g., commercial or Medicare medical policy)
• Support quality-related initiatives and provide expertise in policy and legal reviews
• Provide support for escalated cases, including communication to senior leadership
• Assist in developing and maintaining Medical Director schedules
• Analyze workflows to identify and implement process improvement opportunities
  
  

Job Requirements

• Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine
• Board Certification or Board eligibility by American Board of Medical Specialties or equivalent
• 5+ years related work experience
• Experience in a dynamic, fast-paced environment
• Ability to work independently and collaboratively in a team environment
• Exceptional verbal and written communication skills.
  
  

Preferred

• Experience as a physician reviewer or in utilization management
• Previous leadership or mentoring experience
• Specialty experience in Primary Care
  
  

General Physical Demands

Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

Physical/Environmental Activities

Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally

What We Offer

As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

Medical, dental, vision, life and global travel health insurance;

• Income protection benefits: life insurance, Short- and long-term disability programs;
• Leave programs to support personal circumstances;
• Retirement Savings Plan includes employer contribution and employer match;
• Paid time off, volunteer time off, and 11 holidays
• Additional voluntary benefits available; and
• A comprehensive wellness program
  
  

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Annualized Salary Range: $224,000 - $364,000

Typical Annualized Hiring Range: $224,000 - $280,000

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.

About Us

At GuideWell, we are committed to making diversity, equity and inclusion part of everything we do. We believe in hiring people who represent the communities we serve while creating a workplace that encourages a sense of belonging for everyone, no matter who you are or where you come from.

From students to former military to seasoned professionals, our family of mission-based companies are stronger because of the unique talents and skills of our employees. We believe everyone’s contribution has the power to help people and communities achieve better health. Find your new team today.

About The Team

Florida Blue, A GuideWell Company, has been providing health insurance to residents of Florida for 75 years. Driven by its mission of helping people and communicating to achieve better health, the company serves more than five million health care members across the state. We are looking for exceptional people who will bring our mission to life and succeed by putting the members first.