Medical Director National OP Medicare at Jobgether – United States
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About This Position
This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Medical Director National OP Medicare in United States.
This clinical leadership role focuses on applying deep medical expertise to support utilization management and clinical decision-making for Medicare and Medicare Advantage populations. You will review complex preauthorization requests, evaluate medical necessity, and ensure alignment with evidence-based guidelines, CMS requirements, and organizational policies. The role blends hands-on clinical judgment with structured review processes in a highly regulated healthcare environment. You will collaborate with multidisciplinary teams, including internal clinical staff and external physicians, to ensure appropriate care delivery and resolve clinical questions when needed. A key part of the role involves balancing clinical accuracy, compliance, and efficiency while supporting high-quality patient outcomes. This is a remote position offering meaningful impact on population health and care access for vulnerable patient groups.
- Review and evaluate preauthorization requests for medical services, determining medical necessity and appropriateness based on clinical guidelines, CMS requirements, and internal policies.
- Apply clinical expertise to assess complex inpatient and post-acute care scenarios using available medical records and supporting documentation.
- Communicate determination decisions clearly to internal teams and collaborate with care management when appropriate.
- Engage in physician-to-physician discussions to obtain additional clinical information and resolve complex or disputed cases.
- Support utilization management processes, including claims reviews, appeals, and grievance cases within assigned scope.
- Ensure compliance with regulatory standards, clinical guidelines, and organizational policies in all decision-making activities.
- Contribute to population health initiatives, care management strategies, and cross-functional clinical projects as needed.
- Maintain accurate, timely, and consistent documentation of clinical reviews and determinations.
Requirements:
- MD or DO degree with active, unrestricted medical license in at least one U.S. jurisdiction (and ability to obtain additional licenses if required).
- Minimum 5+ years of direct clinical patient care experience post-residency or fellowship, preferably including inpatient and/or Medicare-related populations.
- Current board certification by ABMS or AOA in an approved medical specialty.
- Strong understanding of clinical guidelines, evidence-based medicine, and healthcare regulatory frameworks (CMS experience preferred).
- Excellent analytical skills with the ability to interpret complex clinical data and make structured decisions.
- Strong verbal and written communication skills, including experience engaging with external physicians and stakeholders.
- Ability to work independently in a structured, compliance-driven environment with minimal supervision.
- Preferred: experience in utilization management, managed care (Medicare Advantage/Medicaid/commercial), or use of tools such as MCG or InterQual.
Benefits:
- Competitive annual salary range: $223,800 – $313,100.
- Eligibility for performance-based bonus incentive plan.
- Comprehensive medical, dental, and vision insurance coverage.
- Retirement savings plan (401(k)) with company support.
- Paid time off including vacation, holidays, parental leave, caregiver leave, and volunteer time.
- Short-term and long-term disability coverage.
- Life insurance and additional wellness-focused benefits.
- Remote work flexibility with home office support and internet stipend (in select states).
- Opportunity to contribute to population health and Medicare care quality at scale.