Medical Director – Part Time

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🔥 3 minutes ago

🗻 New Hampshire, Maryland, +3 more states – Remote

🗻 New Hampshire – Remote 🦀 Maryland – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote ⛰️ West Virginia – Remote

⏱ Part Time

🔴 Lead

👨‍⚕️ Medical Director

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Vālenz® Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2004

⚕️ Healthcare Insurance

💳 Fintech

☁️ SaaS

Healthcare Insurance • Fintech • SaaS

Vālenz® Health is a comprehensive health plan solutions provider that offers a fully integrated platform designed to simplify the complexities of healthcare for employers, payers, providers, and members. The company focuses on enhancing quality and lowering costs through data-driven insights, member navigation, provider networks, and robust claims management. By connecting various stakeholders in the healthcare ecosystem, Vālenz aims to improve health outcomes and streamline the healthcare experience for all involved.

📋 Description

• Provide physician leadership in the development, implementation, and ongoing evaluation of evidence-based clinical guidelines, medical policies, and utilization management protocols to support high-quality, clinically appropriate decision-making. • Ensure clinical programs, utilization review activities, and medical management processes align with current standards of care, evidence-based medicine, accreditation requirements, and applicable federal and state regulations. • Serve as the clinical authority for complex, high-risk, or escalated utilization review cases by providing medical expertise, benefit interpretation, and final medical necessity determinations as appropriate. • Promote consistency, accuracy, and defensibility in medical decision-making by applying sound clinical judgment and established medical necessity criteria across all review activities. • Collaborate with Clinical Operations, Compliance, Legal, and executive leadership to develop, review, and revise clinical and administrative policies, medical necessity guidelines, and benefit interpretation criteria. • Monitor changes in clinical practice guidelines, healthcare regulations, payer requirements, and industry best practices, recommending updates to organizational policies and review processes as necessary. • Provide physician oversight for quality and performance initiatives by reviewing medical management outcomes, analyzing quality metrics, and participating in quarterly Quality Committee meetings and reporting. • Participate in internal audits, accreditation activities, regulatory reviews, and quality improvement initiatives to ensure compliance with organizational standards and continuous operational excellence. • Partner with operational leadership to ensure clinical standards are effectively integrated into utilization review workflows, promoting efficient, evidence-based, and member-focused medical management. • Provide clinical consultation and recommendations regarding post-service medical necessity determinations, appeals, and other medically complex cases requiring physician review. • Serve as a trusted clinical resource and advisor to physicians, nurses, utilization review staff, and cross-functional business partners by providing education, guidance, and consultation on medical policy and clinical best practices. • Participate in interdisciplinary committees, physician advisory groups, and organizational meetings to provide clinical insight and support strategic initiatives. • Foster collaborative relationships with internal and external stakeholders to promote quality outcomes, regulatory compliance, and continuous improvement across medical management programs. • Perform other duties as assigned.

🎯 Requirements

• MD or DO degree with an active, unrestricted medical license • Board certification in a recognized specialty • Experience with utilization management, medical policy development, and clinical program oversight • Familiarity with applicable regulations (e.g., CMS, URAC, and state-specific requirements) • Strong interpersonal, organizational, and analytical skills • Active, unrestricted Texas medical license (full licensure, not an administrative license) • Must hold active medical licenses in states that require physician licensure to perform utilization reviews. Current priorities include Maryland, New Hampshire, West Virginia, and Texas. Additional state licenses are preferred as business needs evolve.

🏖️ Benefits

• Competitive benefits package with generous employer subsidies • Flexible and remote working options • 401k with generous employer match and immediate vesting • Personal and professional development opportunities • Supportive family benefits, including paid leave for new family members • Companywide philanthropic program, Valenz Communities Connection