Medical Director

Medical DirectorMedical DirectorFull TimeRemoteLeadTeam 201-500

Location

North Carolina

Posted

66 days ago

Salary

0

Seniority

Lead

Professional Certificate

Job Description

Medical Director

Brighton Health Plan Solutions, LLC

About The Role Brighton Health Plan Solutions, a full-service health plan administrator, is looking for a part-time board-certified physician with interest and experience in managed care utilization and case management to support our team of nurses, social workers, and coordinators. You will be a leader of the team making medical necessity and benefit coverage determinations and provide support and guidance to the case management programs. You have a passion to make healthcare more effective and affordable. The position can be remote, or on-site in our New York office. The Medical Director will be responsible for providing support for our Commercial and Worker’s Compensation self-funded clients seeking cost-effective resolution of their members’ claims. Your interest and help leading and developing our team and maturing the program only makes the opportunity more rewarding. We have been in business for 25 years and leading by example you will help create a culture focused on service, support of quality healthcare service, and medical cost containment for the benefit of our clients and their members. Primary Responsibilities - Provides clinical support for all areas of Medical Affairs. - Review medical files and make coverage and medical necessity determinations using good judgement combined with 3rd party and proprietary medical guidelines. - Advises team nurses on appropriateness of care and services through the care continuum including hospitals, skilled nursing facilities, and home care to ensure quality, cost-efficiency and continuity of care. - Serves as medical expert for care management; reviews and evaluates cases with review nurses; ensures medical care provided meets the standards for acceptable medical care. - Reviews and resolves grievances related to medical quality of care and actively participates in the functioning of the plan’s grievance and appeals processes. - Along with the nurse supervisor and manager, identify opportunities for improvement and collaborate to enhance team performance. - Makes appropriate outreach to community and academic based treating providers wanting to discuss cases. - Identify, critique, and utilize criteria and resources such as national, state, and professional association guidelines and peer reviewed literature to support sound and objective decision making and rationales in reviews. - Collaborate with other departments, i.e. Member Services, Provider Services, Claims and Contracting, to improve performance. - Support the nurses and coordinators to improve their knowledge, independence, and understanding - Performs other duties as required by the business. - Opportunity to interact with sales and account management supporting client needs. - Maintain proper credentialing and state licenses and any special certifications or requirements necessary to perform the job. Essential Qualifications - Board certified MD or DO, with an excellent understanding of the utilization and case management process. - 3 years' experience working in a managed care environment supporting utilization management and case review with medical necessity determinations. - 3 + years of prior clinical practice with boards from any of a wide range of specialties so long as you are self-motivated to stay up to date on a broad range of medical services using resources. such as mcg guidelines, specialty society guidelines, Up-To-Date and other resources to analyze existing cases. - Specialty training in addition to a first board certification highly desirable. - Current, unrestricted clinical license(s). - Board certification by American Board of Medical specialties or American Board of Osteopathic Specialties is required for MD or DO reviewer with a specialty in Orthopedic Surgery (preferred) or General Surgery. - Ability to communicate clearly and concisely, both verbally and in writing. - Knowledge of evidence-based medical guidelines (nationally recognized standards of health care), utilization management, quality improvement and other medical management functions. - Good interpersonal and communication skills to support the team approach. - Demonstrated computer skills & telephonic skills. About At Brighton Health Plan Solutions (BHPS), we’re creating something new and different in health care, and we’d love for you to be part of it. Based in New York City, BHPS is a rapidly growing, entrepreneurial health care enablement company bringing tangible innovation to the health care delivery system. Our team is committed to transforming how health care is accessed and delivered. We believe that cost, quality, and population health are optimized when people have long term relationships with their health care providers – and that’s why we’re creating new products that today do not exist anywhere in the New York/New Jersey market. With a growing labor business under the well-known MagnaCare brand, the launch of Create - a new marketplace of health systems focused on self-insured commercial health plan sponsors, and a successful Casualty business, we’re fiercely committed to positively impacting our partners. Company Mission Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners. Company Vision Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways. *We are an EEO Employer

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Executive Medical Director, Specialty and Pipeline

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Medical Director66 days ago

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United States
$248K - $372K / year
Merck logo

Health Systems Medical Affairs Director - PA, NJ, DE

Merck

Headquartered in Kenilworth, New Jersey, Merck is a global pharmaceuticals company offering products that include biologic therapies, vaccines, prescription med

Medical Director66 days ago

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Full TimeRemoteTeam 10,001+Since 1987H1B Sponsor

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United States
$165K - $214K / year
Job Closed
Vertex Pharmaceuticals logo

Senior Medical Science Liaison - Pain

Vertex Pharmaceuticals

Vertex Pharmaceuticals is a global biotechnology company dedicated to commercializing breakthrough drugs and improving the lives of people with serious diseases

Medical Director66 days ago

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Demonstrates in-depth conceptual and practical knowledge of the role of pharmacists, P&T committees, payers, and Integrated Delivery Networks in the region and possesses an understanding of the impact of payers on patient care delivery. 8. Assists clinical development/clinical operations by fully understanding IB content and presenting IB material at SIV meetings, providing nominations for trial sites as requested, and providing end-of-study data reviews with investigators as needed. 9. Represents Vertex at medical congresses by providing scientific session/abstract coverage, booth staffing coverage, routine TL interactions, contributing to the daily and end-of-congress summaries, and may provide logistical guidance as the “MSL congress lead” through organizing and scheduling abstract/session coverage and preparing and delivering the conference debrief. 10. May serve as a mentor or trainer for colleagues with less experience, assisting with new hire MSL onboarding. 11. Conducts all activities in compliance with Vertex policy and procedures and performs all administrative tasks in a timely manner, such as CRM entry, vehicle mileage reporting, expense reporting, calendar entries, training assignments, etc. Knowledge/Skills: - Previous training in or experience with medical conditions associated with pain - Ability to complete goals within allotted timeframes and deliver high-quality results - Ability to help plan and complete projects in a constantly changing field-based environment - Ability to create innovative solutions to identified issues - Ability to appraise and comprehend medical and scientific literature - Ability to effectively present clinical/scientific information in a credible manner in varied settings - Good knowledge of assigned geographic territory - In-depth understanding of the healthcare regulatory environment - Proficient in using Microsoft Office programs and working in a matrix environment - Apply proficient knowledge of relevant disease and disease management protocols, healthcare environment, and competitors to articulate the medical and scientific value of our products - Demonstrated working understanding around compliance and regulatory frameworks governing the pharmaceutical industry and conducts compliant interactions with internal and external stakeholders - In-depth knowledge of payers and unique medical information needs to support access and appropriate use of Vertex medicines - Good knowledge of Health Economics and Outcomes Research - Fluent in English & Local Language (oral and written) Requirements: - Minimum requirement for advanced biomedical or life sciences degree (ex. Masters, NP, PA) or Terminal science degree desirable (PhD, PharmD, MD) - Typically requires a minimum of 5 years of experience as a MSL, or in other medical affairs roles in the pharma/biotech industry or the equivalent combination of education and experience *There are multiple field-based regions in the North West. The successful candidate must live within the identified territory near an airport and be willing to travel routinely based on business needs.* The range provided is based on what we believe is a reasonable estimate for the base salary pay range for this job at the time of posting. This role is eligible for an annual bonus and annual equity awards. Some roles may also be eligible for overtime pay, in accordance with federal and state requirements. Actual base salary pay will be based on a number of factors, including skills, competencies, experience, and other job-related factors permitted by law. At Vertex, our Total Rewards offerings also include inclusive market-leading benefits to meet our employees wherever they are in their career, financial, family and wellbeing journey while providing flexibility and resources to support their growth and aspirations. From medical, dental and vision benefits to generous paid time off (including a week-long company shutdown in the Summer and the Winter), educational assistance programs including student loan repayment, a generous commuting subsidy, matching charitable donations, 401(k) and so much more. #HYBRID Pay Range: $171,300 - $256,900 At Vertex, our Total Rewards offerings also include inclusive market-leading benefits to meet our employees wherever they are in their career, financial, family and wellbeing journey while providing flexibility and resources to support their growth and aspirations. From medical, dental and vision benefits to generous paid time off (including a week-long company shutdown in the Summer and the Winter), educational assistance programs including student loan repayment, a generous commuting subsidy, matching charitable donations, 401(k) and so much more.

Massachusetts + 2 moreAll locations: Massachusetts | Michigan | Indiana
$171.3K - $256.9K / year