Medical Director

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing whole‑person care to Senior and Medicaid populations through advanced value‑based models. Our provider network is comprised of more than 6,000 health‑care providers, including primary and specialty care physicians, hospitals and ancillary providers. We have operated in the Arizona market for more than 12 years, are based in Chandler, Arizona, and are an affiliate of Heritage Provider Network. As a leading value‑based provider organization, we are committed to improving the quality of care, delivering excellent member and provider experiences, and reducing cost. Position Duties & Responsibilities Conduct clinical review of cases for Prior Authorizations – evaluate pre‑service requests using MCG guidelines to determine medical necessity and alignment with health‑plan criteria. Conduct clinical review cases for Concurrent Reviews – assess inpatient and ongoing treatment plans in real time, applying MCG criteria to support safe discharge planning and appropriate length of stay. Retrospective Reviews – review services rendered post‑care to ensure clinical appropriateness and documentation accuracy per MCG and regulatory standards. Apply clinical practice guidelines and conduct medical necessity determinations – utilize MCG care guidelines and evidence‑based medicine to review service requests; make determinations that balance quality care, cost‑effectiveness, and compliance with CMS and plan‑specific policies. Collaborate with case management and care coordination teams – partner with RNs, social workers, and care coordinators to support integrated care planning, identify barriers to discharge or treatment, and ensure coordinated transitions across settings. Participate in disease and chronic condition management initiatives – contribute clinical insight to population health efforts and care pathways, particularly in managing high‑risk chronic conditions. Collaborate in developing targeted interventions to reduce avoidable utilization. Conduct drug utilization reviews and evaluate new medical technologies – review pharmaceutical requests and utilization trends for alignment with clinical evidence and formulary guidelines. Assess the clinical benefit of emerging technologies or procedures and support policy development as needed. Support transplant case oversight – review transplant‑related medical records and authorizations to ensure clinical appropriateness, timeliness, and compliance with payer protocols and transplant center requirements. Analyze data for clinical and operational improvement – use utilization trends, denial rates, and outcome metrics to identify opportunities for process improvement and provide actionable recommendations that support efficiency, regulatory compliance, and member outcomes. Ensure timely review and documentation aligned with regulatory requirements – complete medical reviews within established turnaround times; ensure all determinations are thoroughly documented in accordance with CMS, URAC, and NCQA standards, as well as internal SOPs. Participate in special projects and quality improvement initiatives as assigned – provide clinical leadership in cross‑functional teams for initiatives such as accreditation readiness, provider education, documentation improvement, or corrective action planning. Other duties as assigned. Education, Training and Experience Current Arizona license to practice medicine without restrictions. Medical Doctorate or Doctor of Osteopathy degree required with appropriate board certification or qualification and level of expertise typically gained through 5 years of clinical practice. 3 to 5 years of medical administrative experience, preferably with emphasis on managed care members and Medicare rules and regulations. Experience in developing utilization protocols and supporting and motivating the clerical and nursing staff. Confidence in medical decision‑making and strong peer communication skills. Strong/creative UM experience and realistic approach to case management. Ability to research and integrate payor requirements into AZPC processes. Ability to interact with all levels of management, physicians, staff, health‑plan representatives, and outside agencies/vendors. Possess excellent communication, organizational, and influencing skills. Knowledge of computers and experience using MS Office programs (Word, Excel, Outlook, PowerPoint). This role requires 60 days full‑time in‑office presence; hybrid options will be available after the 60‑day period. Compensation The salary range for this position is: $225,000 – $275,000. #J-18808-Ljbffr