Medical Director

RxBenefits • Jackson, MS • 1h ago

The Medical Director, Utilization Management provides clinical leadership and oversight for RxBenefits' utilization management (UM) programs, ensuring that medical and pharmacy review activities are clinically appropriate, evidence-based, and compliant with applicable regulatory and accreditation standards. This role focuses on translating clinical knowledge into business strategy, supporting internal stakeholders in improving clinical outcomes, operational efficiency, regulatory compliance, and assisting in peer-to-peer consultation. The Medical Director also contributes to quality improvement initiatives and supports regulatory and accreditation activities impacting RxBenefits' utilization management programs.

Essential Job Responsibilities Include:

Utilization Management Review

Review and evaluate prior authorization requests submitted by staff pharmacists or clinical team members that require physician review.

Conduct clinical medical necessity reviews of physician or member at the first and second levels, as appropriate.

Serve as a peer-to-peer consulting physician as needed, when regulations allow

Provide medical rationale and documentation supporting appeal decisions.

External Review Coordination

Coordinate with and audit third-party external review agencies to ensure timely and accurate completion of third-level appeals.

Collaborate with and audit external reviewers to ensure fair, evidence-based determinations.

Utilization Management Compliance

Support Utilization Management operations by providing clinical expertise for formulary-related decisions, coverage determinations, and other benefit-aligned activities.

Assist with responsibilities related to formulary management, utilization review processes, and related initiatives (e.g., UM policies, clinical criteria updates).

Serve as a member of the internal Utilization Management Committee.

Collaborate with Legal and Compliance teams to ensure adherence to all applicable state and federal regulations governing medical director oversight and utilization management practices.

Regulatory Oversight

Serve as the Medical Director of record for multiple states for the utilization management review program.

In coordination with Legal, maintain up-to-date knowledge of regulatory requirements related to medical necessity review, prior authorization, and appeals.

Participate in internal audits, compliance reviews, and quality improvement initiatives.

Support documentation and process updates to ensure regulatory readiness.

Stakeholder Collaboration

Serve as a thought leader on member health & welfare, benefit design and new lines of business

Provide insight to clients/brokers regarding coverage determination as needed

Required Skills / Experience:

Doctor of Medicine or Osteopathy from an accredited institution

Active, unrestricted license to practice medicine

Multiple State licenses preferred

5+ years of professional medical experience after completing residency training

Demonstrated experience in utilization management and prior authorization required

Pharmacy knowledge required; specialty drug utilization experience preferred

Strong analytical skills and problem-solving skills

Ability to translate clinical insights into business strategies and client solutions

Exceptional collaborative partner with internal and external stakeholders

Excellent written, verbal, and presentation skills

Proficiency in Microsoft Office

Occasional travel required

RxBenefits provides equal opportunities for everyone who works for us and everyone who applies to join our team, without regard to sex or gender, gender identity, gender expression, age, race, religious creed, color, national origin, ancestry, pregnancy, physical or mental disability, medical condition, genetic information, marital status, sexual orientation, any service, past, present, or future, in the uniformed services of the United States (military or veteran status), or any other consideration protected by federal, state, or local law.

Similar Jobs

Registered Nurse-Diabetes Educator

Veterans Affairs, Veterans Health Administration • Jackson, MS • 33min ago

Hospital & Medical

Summary The Registered Nurse-Diabetes Educator is responsible for providing expert, evidence-based diabetes education to staff and patients. Provides educational instruction and training for diabetic patients throughout...

33min ago

Go to Apply

Medical Records Administration Specialist - Health Administration

Veterans Affairs, Veterans Health Administration • Jackson, MS • 54min ago

Hospital & Medical

Summary The Medical Records Administration Specialist provides health information and medical record professional consultation and administrative assistance to the Health Information Management Department and to the medi...

54min ago

Go to Apply

Medical Lab Scientist Blood Bank (R00044486)

The University of Mississippi Medical Center (UMMC) • Jackson, MS • 2h ago

Hospital & Medical

Thank you for your interest in career opportunities with the University of Mississippi Medical Center. Please review the following instructions prior to submitting your job application: Provide all of your employment his...

2h ago

Go to Apply

Physical Therapist, Home Health

AccentCare, Inc. • Clinton, MS • 4h ago

Hospital & Medical

Overview Physical Therapist / PT, Home Health Location: Clinton, MS - Office location Position: Physical Therapist Position Type: Full time Remote/Virtual Position: No Coverage Area: Hinds County/Jackson, MS Metro Area F...

4h ago

Go to Apply

Acute Care Registered Nurse (RN) - Full-time/ Nights

Select Medical • Jackson, MS • 4h ago

Hospital & Medical

Overview Position: Acute CareRegistered Nurse (RN)/ Registered Nurse (RN) Full Time Nights Location: Jackson, MS Schedule: Nights, 12hr, 7p-7a Sign-on Bonus: $10,000 Select Specialty Hospital Jackson is a critical illnes...

4h ago

Go to Apply

Staff Clinical Consultant

Oracle • Jackson, MS • 1d ago

Hospital & Medical

Job Description Responsible for driving the client through the design of clinical and business processes, solution and technology workflow, and successful adoption that will lead to achieved value. Manage ongoing relatio...

1d ago

Go to Apply

Senior Manager, Medical Science Liaison

Edwards Lifesciences • Jackson, MS • 2d ago

Hospital & Medical

Patients are at the heart of everything we do. As part of our Medical Affairs team, you'll foster internal and external collaboration to generate and disseminate evidence-based clinical practices to help impact patient l...

2d ago

Go to Apply

Pharmacy Operations-Account Manager

Cardinal Health • Jackson, MS • 3d ago

Hospital & Medical

Cardinal Health Sonexus Access and Patient Support helps specialty pharmaceutical manufacturers remove barriers to care so that patients can access, afford and remain on the therapy they need for a better quality of life...

3d ago

Go to Apply

Director, Clinical Management

Otsuka America Pharmaceutical Inc. • Jackson, MS • 4d ago

Hospital & Medical

Job Summary In collaboration with the Senior Director of Clinical Management, the Director is responsible for the operational strategy and management of Otsuka clinical programs, including coordination with other relevan...

4d ago

Go to Apply

Senior Field Sales Manager -Healthcare (Western United States)

Wolters Kluwer • Jackson, MS • 4d ago

Hospital & Medical

This role engages healthcare providers, payers, consultants, insurance companies, corporations, and state and local government agencies to drive sales and ongoing customer success for Wolters Kluwer Healthcare Regulatory...

4d ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)