Senior Managing Medical Director

Who we are Founded in 1999 and headquartered in Central Ohio, we’re a privately-owned, independent healthcare navigation organization. We believe that no one should have to navigate the cost and complexity of healthcare alone, and we’re on a mission to make healthcare simpler and more effective for our millions of members. Our big-hearted, tech-savvy team fights to ensure that our members get the care they need, when they need it, at the most affordable cost – that’s why we call ourselves Healthcare Warriors®. We’re committed to building diverse and inclusive teams – more than 2,000 of us and counting – so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every requirement. The Senior Management Medical Director provides clinical and operational leadership for utilization management programs while overseeing the performance, development, and management of the Medical Director team. This role serves as an advanced physician leader responsible for the most complex clinical matters, enterprise-level clinical influence, physician guidance and management, quality leadership and senior stakeholder engagement. The role supports organizational growth through utilization management expertise, clinical quality initiatives, client engagement, audit readiness, and strategic collaboration with executive leadership. Essential Roles and Responsibilities (State the activities that are essential to job success; begin each statement with an active verb and end with some purpose; group like or similar activities under a common heading; assign percent of time spent for each group; percent of time spent must add up to 100%) Essential Tasks/Duties/Responsibilities Medical Director Leadership and Management (30%) • Provide direct leadership, management and guidance to the Medical Director team. • Recruit, interview, and participate in hiring decisions for new Medical Directors. • Lead and coordinate onboarding, orientation, training, shadowing, and competency development activities for newly hired Medical Directors. • Maintain onboarding, training, credentialing, and competency documentation to support URAC, NCQA, and organizational requirements. • Manage Medical Director schedules, PTO requests, coverage planning, and staffing assignments to ensure operational continuity. • Conduct performance evaluations and provide ongoing coaching, mentoring, and professional development. • Monitor Medical Director productivity, decision quality, turnaround times, and documentation accuracy. • Lead Medical Director clinical rounds and facilitate clinical calibration discussions. • Arrange and monitor inter-rater reliability (IRR) activities and physician quality reviews. • Collaborate with Quality and Operations teams to develop quality scorecards, identify performance trends, and implement targeted improvement plans. • Support employee relations activities and physician engagement initiatives in partnership with Human Resources. • Structure and delegate Medical Director pod alignment and responsibilities based on organizational needs, growth, and client demands. • Serve as the senior escalation resource for complex clinical reviews, quality concerns, and physician consultation. Utilization Management Operations and Clinical Oversight (50%) • Conduct high-cost claimant (HCC) reviews and complex case reviews to ensure appropriate utilization and achievement of client commitments. • Identify gaps in care, utilization trends, and opportunities for intervention through clinical review activities. • Support intensive case management strategies for high-risk and medically complex members. • Serve as a clinical subject matter expert for utilization management operations across the organization. • Render utilization review determinations for prior authorization, concurrent review, and other medical necessity reviews based on evidence-based criteria and clinical judgment. • Review and issue denial determinations when requested services do not meet established criteria and clinical standards. • Provide clinical consultation and guidance to nurses, care coordinators, and other interdisciplinary team members. • Support chronic disease management and member engagement initiatives through clinical consultation and review. • Participate in intra-organizational referrals and multidisciplinary case discussions. • Initiate procedural and operational improvements to address recurring utilization management issues and improve efficiency. • Evaluate clinical and utilization data to identify trends, risks, and opportunities for improved member outcomes and operational performance. • Conduct peer-to-peer discussions with requesting and treating providers as appropriate. • Review and render appeal determinations when independent physician review is required. Client, Quality, Audit, and Strategic Leadership (20%) • Support client re