Group Health Medical Director

OverviewWe are seeking a high‑performing Physician Reviewer to join our Group Health division. The role is responsible for delivering timely, defensible utilization review determinations across a high-volume, fast-paced environment. Reviews span multiple case types, including preauthorization, appeals, DRG clinical validation, benefit review, and experimental/investigational determinations.Key ResponsibilitiesPerform utilization review for preauthorization requests, appeals (first and second level), independent external reviews, DRG validation and clinical review, benefit and coverage determinations, and experimental/Investigational (E/I) review.Apply evidence‑based criteria and guidelines, including InterQual, MCG, CMS guidelines (including 2‑Midnight Rule), LCD/NCD, and client‑specific policies.Produce clear, concise, defensible clinical rationales.Maintain high accuracy and consistency across determinations.Meet or exceed turnaround time (TAT) expectations, including urgent cases.Participate in peer‑to‑peer discussions as needed.Collaborate with QA and operational teams to ensure quality and compliance.Performance MetricsHigh daily review volume with strong accuracy.Consistent adherence to client‑specific requirements.Ability to manage short‑TAT and urgent cases efficiently.Clear, audit‑ready documentation.Required QualificationsMD or DO, board‑certified in Internal Medicine, Family Medicine, or similar.Active, unrestricted medical license.Prior utilization review experience, preferably in a health plan or IRO environment.Familiarity with InterQual, MCG, and CMS guidelines.Strong clinical judgment and documentation skills.Ability to work independently in a high‑throughput environment.Technical SkillsProficiency with standard business tools (Google Workspace, Microsoft Office).Comfortable working across multiple systems, including internal platforms and client‑specific portals.Strong navigation and documentation skills within web‑based applications.Ability to manage multiple systems/screens simultaneously in a high‑throughput environment.Familiarity with Mac operating systems.Work EnvironmentRemote work from home.Full‑time, Monday–Friday.Availability for occasional weekends and holiday coverage for urgent reviews.BenefitsMedical, dental, and vision coverage for employee and family. Voluntary life insurance options for employee, spouse, and children. Additional voluntary benefits including hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Basic life insurance, short‑term disability, and long‑term disability coverage at no cost. Paid time off, 401(k) plan with company match, Apple equipment, and media stipend for remote workspace. #J-18808-Ljbffr