Position Details

Salary $179K – $307K USD / year

Type Full-Time

Experience executive

Exp. Years 3-5 years of clinical practice experience past fellowship training is desirable; (minimum requirements do not specify years)

Education MD or DO

Category Engineering (Non-Software)

About this role

This role supports medical management staff by ensuring timely and consistent clinical case reviews for a board-certified specialty. The Associate Medical Director makes physician-to-physician calls for medical information and determines medical necessity for services as well as grievance and appeals, escalating cases when Medical Director review or policy interpretation is needed.

Key Responsibilities

Ensure timely completion of clinical case reviews for their board certified specialty
Make physician to physician calls to gather medical appropriate information for medical necessity determinations
Make medical necessity determinations for grievance and appeals appropriate for their specialty
Ensure consistent use of medical policies when making medical necessity decisions
Escalate cases requiring Medical Director review or policy interpretation to supervisors

Technical Overview

Primarily clinical operations focused on utilization-style decisioning: medical necessity determinations and consistent application of medical policies. Works in a virtual model with in-person training sessions, coordinating with medical management staff and escalating complex cases for review.

Ideal Candidate

The ideal candidate is an MD or DO with an active unrestricted medical license and the required board certification through ABMS or AOA. They have strong experience performing clinical case reviews and making medical necessity determinations for grievance and appeals in their board-certified specialty, with Sleep Medicine board certification being strongly preferred.

Must-Have Skills

MD or DOBoard certification approved by one of the following certifying boards is requiredwhere applicable to duties being performed: American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)active unrestricted medical license to practice medicine or a health profession

Nice-to-Have Skills

Board Certification by American Board of Medical Specialties in Sleep Medicine3-5 years of clinical practice experience past fellowship training

Required Skills

clinical case reviewsphysician to physician callsmedical necessity determinationsgrievance and appealsmedical policiesmedical policy interpretationMedical Director review

Hard Skills

clinical case reviewsphysician to physician callsmedical necessity determinationsgrievance and appealsmedical policy interpretationmedical management staff supportboard-certified specialty case review for timelinessSleep Medicine board certificationutilization review (implied by medical necessity determinations)

Soft Skills

physician communicationclinical decision-makingattention to medical policy consistencyprofessional judgmentcollaboration with medical management staffescalation and escalation judgment

Certifications

Required

Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO)Board certification approved by American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)

Preferred

Board Certification by American Board of Medical Specialties in Sleep Medicine

Industry & Role

Industry Healthcare

Job Function Lead clinical medical decision operations for Sleep Medicine case review and medical necessity determinations

Role Subtype Medical Director

Keywords for Your Resume

Associate Medical Director - Sleep MedicineClinical Operations Associate Medical DirectorCarelon Medical Benefits Managementmedical management staffclinical case reviewsphysician to physician callsmedical necessity determinationsgrievance and appealsmedical policiespolicy interpretationMedical Director reviewMDDOAmerican Board of Medical Specialties (ABMS)American Osteopathic Association (AOA)Board CertifiedSleep Medicineactive unrestricted medical licensevirtual full-timein-person training sessions

Deal Breakers

Must have MD or DO, Must have an active unrestricted medical license, Must have board certification approved by ABMS or AOA (where applicable to duties being performed)

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