Medical Director

RxBenefits • Providence, RI • 3h 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.

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