Role Description Position in this function is responsible, in part, as a member of a team of medical directors, for the overall quality, effectiveness and coordination of the medical review services. Additionally, performs Utilization Management reviews and directs/coordinates aspects of the utilization review staff activities, and participates in the Quality Improvement programs for the company. The Medical Director also provides/assists in the direction and oversight in the development and implementation of policies, procedures and clinical criteria for all medical programs and services and may serve as a liaison between physicians, and other medical service providers in selected situations. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: - Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations. - The focus of the coverage reviews will be various types of musculoskeletal and other medical/surgical services which will include prior authorizations for spine surgery. - Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements. - Support compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers). - Work with clinical staff to coordinate all the necessary coverage reviews and provide feedback to staff who do portions of the coverage reviews. - Engage with requesting providers as needed in peer-to-peer discussions. - Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews. - Participate in periodic clinical conferences / calls and in ongoing internal performance consistency reviews. - Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy. - Communicate and collaborate with other internal partners. - Call coverage rotation. Is available for periodic weekend and holiday coverage as needed for telephonic and remote computer expedited clinical decisions. - Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable. - Good understanding of professional performance measurement and related possible discussions/interventions with selected providers/groups/organizations. Qualifications - Current, active and unrestricted medical license. - Current Board Certification in Orthopedic Surgery or Neurosurgery. - 5+ years clinical experience post residency in Orthopedic Surgery or Neurosurgery to include experience with musculoskeletal/ spine surgery. - Sound understanding of Evidence Based Medicine (EBM). - Proficient with MS Office (MS Word, Email, Excel, and Power Point). - Excellent computer skills and ability to learn new systems and software. - Excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel. - Willing to obtain additional licenses as needed. Requirements - Active license in South Carolina, Minnesota or Texas, but candidates with an active license in other states are acceptable. - ABMS or other nationally recognized further specialized certifications. - Experience in managed care UM activities/ coverage reviews. - Experience with integration of clinical and financial data, development of utilization and performance reporting tools, and communication of performance data to physicians and other health care providers. - Possess leadership skills in working with other physicians, knowledge of the overall medical community and the local / regional managed care environments. Benefits - Comprehensive benefits package. - Incentive and recognition programs. - Equity stock purchase. - 401k contribution (all benefits are subject to eligibility requirements). Application Deadline This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

• Work closely with the General Manager of Wellness & Weight Health to drive strategic initiatives. • Assist in developing digital clinical products based on existing clinical guidelines, providing data-driven insights to drive cost-effectiveness and quality. • Provide oversight and leadership to the care delivery team. • Lead clinical outcomes studies and contribute to HEOR studies. • Serve as primary liaison to enterprise clinical review boards • Support growth initiatives by engaging with current and prospective partners and clients. • Lead and assist in care delivery innovations and initiatives that will help ensure RVOH continuously advances science, healthcare, and the medical industry, creating scalability and repeatability in these initiatives. • Set up and maintain all clinical standards across the business unit, including a Clinical Advisory Board made up of internal and external clinicians and executives • Review and approve clinical protocols for our asynchronous and telehealth platform • Set the talent bar and foster a culture that embodies HLTHY behaviors, values strong people leadership, and has a high-performance mindset • Build and maintain a strong bench of practicing clinicians and continue to onboard certified physicians and expert FTEs as needed • Remain updated on the latest developments in healthcare and the healthcare industry, including new nutritional, fitness, pharma, and technology development trends

Role Description Innovaccer is seeking a Senior Director, Medical Management with deep experience in utilization management, prior authorization, and care coordination workflows to help shape the next generation of AI-enabled healthcare products. Working within the Clinical Innovation team, this leader will partner with product, analytics, and AI teams to design and operationalize solutions that automate administrative processes, improve clinical decision support, and streamline payer–provider workflows. The role will bring real-world nursing and utilization management expertise into product development to ensure that Innovaccer’s solutions reflect the needs of nurses, care managers, and utilization review teams across health systems and health plans. A Day in the Life - Product & Workflow Innovation: - Serve as the primary clinical operations expert for solutions addressing utilization management, prior authorization, and related workflows. - Translate real-world nursing and utilization review workflows into scalable digital product capabilities. - Partner with product managers to define requirements, user stories, and workflow designs. - AI & Automation Enablement: - Collaborate with data science and AI teams to identify opportunities for automation in utilization review, documentation review, and clinical decision support. - Help design AI-enabled workflows that reduce manual administrative work for nurses and care management teams. - Clinical Validation & Usability: - Ensure product capabilities align with actual nursing workflows and regulatory expectations. - Participate in product testing, workflow simulations, and usability validation. - Customer Insight & Implementation: - Provide subject matter expertise during product pilots and early implementations. - Help Innovaccer understand how solutions will be used by nurses, utilization review teams, and care managers in provider and payer organizations. - Innovation Leadership: - Work closely with the Chief Innovation Officer to identify opportunities for new clinical workflow products. - Help shape the clinical strategy for automation across administrative and clinical operations. Qualifications - Registered Nurse (RN), BSN required; MSN or advanced clinical informatics training preferred - 5–10+ years of experience in utilization management, care management, or prior authorization operations - Experience in health systems, health plans, or delegated risk organizations - Familiarity with clinical documentation review, medical necessity criteria, and utilization review processes - Exposure to health IT, analytics platforms, or AI-enabled healthcare solutions strongly preferred Benefits - Generous Paid Time Off: Recharge and relax with 20 days of fixed time off per year, in addition to company holidays—because we believe work-life balance fuels performance. - Best-in-Class Parental Leave: Spend quality time with your growing family. We offer one of the industry’s most generous parental leave policies to support you during life’s most important moments. - Recognition & Rewards: We celebrate wins—big and small. Get rewarded with monetary incentives and company-wide recognition for your impact and dedication. Your hard work won’t go unnoticed. - Comprehensive Insurance Coverage: Stay covered with medical, dental, and vision insurance, plus 100% company-paid short- and long-term disability and basic life insurance. Optional perks include discounted legal aid and pet insurance.

Role Description AMDEX Corporation’s subsidiary company, Avar Consulting, is seeking a Medical Director for its contract with the Center for Medicare and Medicaid Services. - Conducting audits, namely beneficiary appeals, in specific BFCC-QIO service areas to determine if the BFCC-QIO's operations, programs, or projects in these service areas are functioning effectively and efficiently. - These audits will include a review of a designated number of cases per contracted service area. - The audits shall include IRR of beneficiary appeals to measure the level of agreement between BFCC-QIO decisions and the contractor’s decisions. - On an annual basis, the contractor shall perform IRR reviews on: - 2,000 cases each for Medicare FFS Post-Acute Appeals and MA Post-Acute Appeals. - 1,100 cases each for Hospital Discharge Appeals and Hospital Observation Status Appeals. Qualifications - Licensed Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) in the United States (Note: Licensure must be verified annually). - Experience in patient care and medical peer review. - Experience overseeing medical care in healthcare organizations or facilities. - Experience coordinating medical care, developing, and evaluating resident care policies. - Knowledge of current and emerging healthcare industry trends. - Ability to advise on physician and clinical practice issues. - Ability to ensure systems exist for sound medical care, monitoring, documentation, and compliance with regulations. - Ability to mentor and influence positive change. - Excellent oral and written communication skills. - Knowledge of Medicare coverage and payment policies. - Experience educating staff on Medicare policy and review application. - Experience in collaborating with physician and nurse reviewers according to Medicare policy. Company Description - Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC QIOs) help Medicare beneficiaries exercise their right to high-quality health care, by managing beneficiary complaints and quality of care (QoC) reviews, as well as handling cases in which beneficiaries want to appeal a health care provider’s decision to discharge them from a hospital or discontinue other types of services. - Avar has contributed significantly to the BFCC QIO program’s evolution across the last several years and was the first ever small business to win a QIO contract. - Avar has incorporated analytics and data-driven improvements, innovation, and collaboration to deliver and drive beneficiary oversight, protection, and engagement. - As the BFCC National Coordinating Oversight & Review Center (BFCC-NOCRC), Avar has played a crucial role in advancing CMS’ strategic agenda. - Avar is a woman-owned small business specializing in program evaluation and policy assessment; survey research; data collection, management, analysis, and reporting; and ancillary information technology and communication support services. - Avar is a wholly owned subsidiary of AMDEX Corporation. - Avar holds similar analytics contracts with HHS, DOL, and Dept of Education. - AMDEX Corporation is a Women Owned Small Business with over 35 years supporting government agencies; HHS, NIH, CDC, Department of Homeland Security, Census Bureau.