Job Description
Job Description
Job Summary The Medical Director is responsible for overseeing clinical and operational functions within the Health Plan. This role outlines general duties, requirements, and expectations, ensuring compliance with regulatory and accreditation standards while supporting quality, efficiency, and patient-centered care.
Key Responsibilities
- Handle utilization management determinations, appeals, and grievances in compliance with Medicare, MassHealth, NCQA, and Division of Insurance requirements.
- Review clinical services and quality incidents requiring physician involvement.
- Provide medical necessity determinations to support special investigations, fraud, waste, and abuse cases.
- Collaborate on the development of health plan medical policies.
- Assess new, emerging, and existing technologies for coverage appropriateness.
- Partner with clinical leaders to ensure medical service expenditures remain within budget.
- Work with business development, quality, finance, and medical management teams to improve care quality and cost efficiency across the provider network.
- Consult with network management staff and support education programs for clinicians.
- Develop and deliver presentations for clinical staff on relevant topics.
- Represent the Health Plan at external forums and committees as needed.
- Collaborate with physicians, hospital leaders, and vendors regarding enrollee care and services.
- Monitor performance metrics and audits to identify areas for improvement and ensure compliance.
- Build strong relationships that reinforce the Health Plan as a people-first organization.
- Integrate diversity, equity, and inclusion principles into all aspects of work.
- Perform other duties as assigned.
- 3-5 Years of Experience Needed.
Required Qualifications
- Active, unrestricted physician license in state.
- Ability to immediately report any license restriction, suspension, or loss.
- Strong communication and collaboration skills with internal and external stakeholders.
- Experience in utilization management, policy development, and clinical oversight.
Preferred Qualifications (if any)
- Prior leadership experience in a health plan or managed care environment.
- Familiarity with regulatory and accreditation standards (Medicare, MassHealth, NCQA).
Certifications (if any)
- Board certification in a medical specialty (preferred).
Education: Bachelors Degree
Company DescriptionCompunnel Software Group, Inc., the parent organization of Compunnel Healthcare has expanded its staffing services within the blooming healthcare industry. Born from company’s 35+ years of experience in Compunnel Healthcare provides customized, cost-effective solutions to your healthcare organization’s multiple staffing needs.
Company Description
Compunnel Software Group, Inc., the parent organization of Compunnel Healthcare has expanded its staffing services within the blooming healthcare industry. Born from company’s 35+ years of experience in Compunnel Healthcare provides customized, cost-effective solutions to your healthcare organization’s multiple staffing needs.