Medical Director, Utilization Management

COMPANY OVERVIEW:

HealthAxis is a prominent provider of core administrative processing system (CAPS) technology, business process as a service (BPaaS), and business process outsourcing (BPO) capabilities to healthcare payers, risk-bearing providers, and third-party administrators. We will transform the way healthcare is administered in the United States by providing innovative technology and services that uniquely solve critical healthcare payer challenges negatively impacting member and provider experiences.

We prioritize the well-being, needs, and dignity of individuals with empathy guiding all interactions. We embrace curiosity, foster creativity, and leverage technology to enhance healthcare accessibility and efficiency. We uphold the highest ethical standards, maintain transparency, and take responsibility to build trust. We drive excellence through teamwork, partnerships, and dedication to continuous improvement. We are committed to equitable, purpose-built healthcare solutions that benefit all communities.

We're not just about business – we're about people. Our commitment to a people-first approach shapes everything we do, from collaborating as a team to serving our valued clients. We believe that creating a vibrant and human-centric environment can inspire engagement, empower our team members, and ignite a sense of purpose in all that we accomplish.

PURPOSE & SCOPE:

The Medical Director of Utilization Management is responsible for working hand-in-hand with senior leaders to provide medical expertise and decision making within the Utilization Management team. This role will be responsible for ensuring that healthcare services are medically necessary, appropriately utilized, and meet the highest standard of quality. Adhere to standard Federal, State and/or CMS compliant medical policies within the organization. This role involves reviewing clinical cases, providing medical expertise, and collaborating with various stakeholders to ensure efficient and effective healthcare delivery. All departmental workflows and document retention must be adhered to by the Medical Director. At times, peer to peer phone and/or teams calls may be required based upon business and contractual needs.

PRINCIPAL RESPONSIBILITIES AND DUTIES:

• Assists in development and maintaining an efficient UM program to meet the needs of the health plan members and commensurate with company values.

• Educates primary care physicians regarding systems, structures, processes and outcomes necessary for assurance of regulatory compliance related to market activities.

• Develops strategies for improving all aspects of market performance including RAPS, membership, and medical management.

• Participates in case reviews and medical necessity determination.

• Serve as a resource for clinical staff, offering guidance on complex cases and medical necessity.

• Conducts post service reviews issued for medical necessity and benefits determination coding.

• Maintains accurate and thorough documentation of activities and decisions.

• Analyzes aggregate data and reports to primary care physician.

• Serves as the liaison between physicians and health plan Medical Directors.

• Performs secondary review when prior authorization, initial and concurrent reviews do not meet medical necessity criteria or level of care appropriateness.

• Participates in the Grievance and Appeal review process to provide recommendations.

• Utilize clinical expertise to identify the salient points within a case review.

• Identify process improvements opportunities and inefficiencies.

• Interact with external physicians as needed – through secure messaging, text, and potential phone calls.

• Opportunity to be involved in additional responsibilities such as special projects, focus groups, new Medical Director training, or organizational committees.

• Collaborate with management and operations team members to propose strategic, operational, and technological solutions for improving quality.

• Other duties as assigned.

EDUCATION, EXPERIENCE AND REQUIRED SKILLS:

• Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) degree.

• Preferably, Board Certified Family Practitioner or Emergency Medicine Physician.

• Unrestricted license in at least one state within the United States.

• 5+ years of clinical practice experience.

• 2+ years of experience in utilization management activities.

• Proficiency with Microsoft Office applications.

• M.D or D.O and five (5) years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.

• Board Certified in an American Board of Medical Specialties Board, and an active, unrestricted license to practice medicine in a state or territory of the United States.

• Previous experience with administrative oversight of the medical function of an insurance (or related) company.

• Previous experience leading a team of professionals.

• A strong perspective on how to increase operational excellence and automation through process improvement and technology partnerships.

• Strong interpersonal skills, with the ability to regularly interact with various client departments/project teams.

• An ability to balance critical thinking with hands-on execution. Forward-thinking strategic leader.

• Results-driven. Ability to work in a fast-paced and changing environment and react professionally under pressure.

• Self-starter with strong organizational skills. Excellent oral and written communication skills.

COMPENSATION, BENEFITS, & WELL-BEING:

At HealthAxis, we believe people do their best work when they feel valued, supported, and treated fairly. We take a transparent and people-first approach to compensation and benefits that reflects the expertise and impact each team member brings.

The pay range for this position is $150.00–$160.00 per hour. Actual compensation within this range will be determined based on job-related factors, including but not limited to: skills, experience, geographic location, and internal equity.

In addition to compensation, we offer a comprehensive benefits package designed to support your health, financial security, and work-life balance, including:

• Health insurance (Medical, Dental, and Vision coverage available)

• Flexible Spending and Health Savings Account options

• Company-paid life insurance and disability coverage

• 401K Retirement Plan with Company match

• Paid Time Off, paid holidays, and paid volunteer time

• Educational Assistance Program and professional development courses

• Employee Assistance Program and other wellbeing resources

• Fully remote work environment with flexible scheduling options

Benefits are available to eligible full-time employees and may vary by location.

HealthAxis is an Equal Opportunity Employer where all qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, sex (including sexual orientation, transgender status or pregnancy), age, disability, genetic information, military status, veteran status, marital status, political affiliation, or any other characteristic protected by applicable federal, state or local laws.