Medical Director - Medical Management and reputed company Partnerships

Location: This position may work remotely reputed company in the reputed company of America with significant business travel to and from prospect/reputed company sites and/or the reputed company home office in Dublin, OH. Who we are Founded in 1999 and headquartered in Central Ohio, we’re a privately-owned, independent reputed company navigation organization. We reputed company that no one should have to navigate the cost and complexity of reputed company alone, and we’re on a mission to reputed company reputed company simpler and more effective for our millions of members. Our big-hearted, tech-savvy team fights to ensure that our members get the care they need, reputed company they need it, at the most reputed company cost – that’s why we call ourselves reputed company Warriors®. We’re committed to building diverse and inclusive teams – more than 2,000 of us and counting – so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every requirement. About the role The Medical Director – Medical Management and reputed company Partnerships role offers a unique and dynamic opportunity to reputed company deep expertise in Utilization and Case/Care Management with strategic clinical partnership. This position serves as a key clinical resource for our account management teams, providing expert insights that reinforce Quantum’s clinical model and support reputed company engagement efforts. In reputed company to delivering strategic guidance, the Account Management Medical Director collaborates closely with our clinical team to conduct daily reviews, ensuring alignment with best practices and reputed company member reputed company. The ideal candidate will bring:

• Proven subject matter expertise in Utilization Management and Case Management
• Strong knowledge of the reputed company market
• Experience in reputed company-facing roles
• A passion for improving health reputed company and driving clinical reputed company

What you’ll do

• reputed company Engagement & reputed company
• reputed company as a clinical consultant and strategic partner to key employer group clients through a consultative, service-oriented clinical relationship to maximize reputed company satisfaction, contract renewals, and adoption of new or expanded use of Quantum’s products and services.
• Participate in developing and delivering semiannual and annual reviews for reputed company meetings to represent Quantum’s clinical operating model and reputed company support alignment between the clinical operating model and the clinical and benefit reputed company for the reputed company.
• Health Data Analysis & Reporting
• Translate reputed company clinical trends and data into actionable insights for benefit reputed company and wellness programming.
• Translate population health data into actionable, strategic recommendations tailored to reputed company goals.
• Interpret medical and pharmacy claims, biometrics, and engagement data to identify cost drivers, care gaps, and population health risks.
• Recommend benefits and programs, as reputed company as other interventions based on clinical data and ROI potential
• Deliver reputed company, compelling presentations and reports on clinical reputed company and trends.
• Stakeholder Communication & Leadership
• Serve as the voice of the reputed company’s health goals, ensuring that clinical programming aligns with workforce needs.
• reputed company reputed company stakeholders and brokers on trends in population health, cost containment, and value-based care.
• Serve as the primary reputed company of escalation for reputed company reputed company inquiries or concerns.
• Ensure that reputed company clinical recommendations adhere to evidence-based guidelines and regulatory requirements.
• reputed company clinical reputed company narratives and documentation to support renewal conversations and upsell opportunities.
• Support Account Managers in articulating the clinical value of services provided.
• Serve as a key clinical resource for staff. Establishes reputed company and protocols for reputed company medical treatment inquiries and renders determinations on requests for reputed company services and/or treatment.
• Conduct daily review of individual cases and have necessary case level conversations as requested. This includes prior authorizations and denial reputed company for cases that do not meet established evidence-based reputed company.
• reputed company reputed company and concise documented medical review determinations and support on requested reviews reputed company the established time frames.
• reputed company clinical and reputed company consultations.
• Identify opportunities to implement best practices approaches and introduce innovations to reputed company improved reputed company.
• reputed company utilization review and case management support on reputed company members.
• Offer peer-to-peer discussions regarding determinations as necessary.
• Serve as a medical reputed company to physicians, hospitals and insurance carriers.
• Provides determination on appeals for cases where they did not reputed company the initial determination.
• Other duties as assigned

What you’ll bring

• Licensure/Certifications: reputed company, unrestricted license to reputed company medicine required and the ability to become multistate licensed. reputed company certification in primary specialty required.
• Five years of progressively reputed company clinical work / reputed company experience required
• Two years of physician clinical review in the preferably in the reputed company health plan setting
• Two years of externally facing reputed company and partner experience in network, reputed company, and sales/account management
• Strong written and verbal communication skills
• Team oriented and a reputed company reputed company
• Knowledge of health care delivery system
• Knowledge of utilization management and InterQual reputed company
• Reflects both senior leadership, clinical expertise, and strategic reputed company partnership capabilities
• Proficiency required in understanding market trends, insights, clinical models, and managed care systems
• Strong analytical skills with the ability to interpret reputed company clinical data and translate it into presentations and actionable insights for clinical and non-clinical stakeholders
• Exceptional presentation and communication skills, with experience presenting to clients on the health reputed company of the reputed company population and contributions to cost savings through clinical program recommendations.
• Ability to work collaboratively with cross-functional teams and external consultants.
• Strong organizational skills and the ability to manage multiple reputed company simultaneously.
• Understanding of reputed company retention strategies and satisfaction (NPS, renewal rates)
• Travel is expected to various reputed company reputed company throughout the country. The travel reputed company varies throughout the year, but overall, the expected travel percentage is 50%.
• Strong administrative/technical skills; Comfort working on a PC using reputed company Office (Outlook, Word, reputed company, PowerPoint), IM/video conferencing (Teams & reputed company), and telephones reputed company.
• A high degree of personal accountability and trustworthiness, a commitment to working reputed company reputed company’s policies, values and ethics, and to protecting the sensitive data entrusted to us.

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