Medical Director – Utilization Review

🔥 9 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $260k - $280k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Curative

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2020

🏥 Healthcare

🛡️ Insurance

Healthcare • Insurance

Curative is an employer-focused health insurance company offering a next-generation group health plan that emphasizes affordability, engagement, and simplicity. Their plans promise $0 in-network copays, $0 deductibles, and a single competitive monthly premium, along with a broad provider network, telehealth, an extensive $0-preferred prescription formulary, care navigators, and the Curative Cash Card to eliminate out-of-pocket costs in many settings. Curative markets to employers and brokers while providing members with resources like a Baseline Visit, care programs, online portals, and pharmacy services, and holds an A- rating from AM Best and HITRUST r2 certification.

📋 Description

• Perform comprehensive medical necessity reviews (prospective, concurrent, and retrospective) for a wide range of healthcare services, applying clinical expertise, established medical policies, and evidence-based guidelines. • Conduct thorough prior authorization reviews, ensuring alignment with clinical criteria, regulatory requirements, and contractual agreements. • Lead and conduct effective peer-to-peer discussions with requesting practitioners, providing clear clinical rationales for determinations, facilitating open dialogue, and seeking alternative solutions when appropriate. • Issue medical necessity denials when warranted, providing comprehensive and well-documented rationales in compliance with all relevant regulations and appeal processes. • Collaborate closely with internal teams, including Nurse Practitioners, Care Coordinators, and Operations, to optimize utilization management processes and improve member outcomes. • Contribute to the development, review, and revision of medical policies, clinical guidelines, and utilization management protocols. • Participate in quality improvement initiatives, audits, and committee meetings as required. • Maintain meticulous documentation of all review activities, decisions, and peer-to-peer interactions. • Stay abreast of current medical literature, healthcare trends, regulatory changes, and industry best practices in utilization management. • Champion a member-centric approach while balancing clinical efficacy and cost-effectiveness. • Embrace the fast-paced, evolving nature of a startup environment, demonstrating adaptability and a proactive approach to problem-solving.

🎯 Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school. • Board Certification in a medical specialty. • Active and unrestricted Medical License in at least one US state, with the ability to obtain additional state licenses as needed (Curative will support additional licensure processes). • Minimum of 5 years of clinical practice experience. • Minimum of 2-3 years of experience in utilization management, medical review, or prior authorizations within an insurance or managed care organization. • Demonstrated success in conducting peer-to-peer discussions with external practitioners, with excellent communication and interpersonal skills. • Profound understanding of medical necessity criteria, evidence-based medicine, and healthcare utilization management principles. • Strong analytical and critical thinking skills, with the ability to synthesize complex clinical information and make sound medical decisions. • Exceptional written and verbal communication skills, capable of explaining complex medical decisions clearly and empathetically. • Proficiency with electronic health records (EHR) systems and utilization management software. • Self-motivated, highly organized, and able to manage a high volume of cases effectively in a remote work environment. • A "roll up your sleeves" attitude and a genuine excitement for contributing to a rapidly growing, innovative startup. • No travel required for this position.

🏖️ Benefits

• Curative Health Plan (100% employer-covered medical premiums for you and 50% coverage for dependents on the base plan.) • $0 copays and $0 deductibles (with completion of our Baseline Visit ) • Preventive and primary care built in • Mental health support (Rula, Televero, Two Chairs, Recovery Unplugged) • One-on-one care navigation • Chronic condition programs (diabetes, weight, hypertension) • Maternity and family planning support • 24/7/365 Curative Telehealth • Pharmacy benefits • Comprehensive dental and vision coverage • Employer-provided life and disability coverage with additional supplemental options • Flexible spending accounts • Flexible work options: remote and in-person opportunities • Generous PTO policy plus 11 paid annual company holidays • 401K for full-time employees • Generous Up to 8–12 weeks paid parental leave, based on role eligibility.