Senior Managing Medical Director

Who we are Founded in 1999 and headquartered in Central Ohio, we’re a privately-owned, independent healthcare navigation organization. We believe that no one should have to navigate the cost and complexity of healthcare alone, and we’re on a mission to make healthcare 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, when they need it, at the most affordable cost – that’s why we call ourselves Healthcare 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. The Senior Management Medical Director provides clinical and operational leadership for utilization management programs while overseeing the performance, development, and management of the Medical Director team. This role serves as an advanced physician leader responsible for the most complex clinical matters, enterprise-level clinical influence, physician guidance and management, quality leadership and senior stakeholder engagement. The role supports organizational growth through utilization management expertise, clinical quality initiatives, client engagement, audit readiness, and strategic collaboration with executive leadership. Essential Roles and Responsibilities (State the activities that are essential to job success; begin each statement with an active verb and end with some purpose; group like or similar activities under a common heading; assign percent of time spent for each group; percent of time spent must add up to 100%) Essential Tasks/Duties/Responsibilities Medical Director Leadership and Management (30%) • Provide direct leadership, management and guidance to the Medical Director team. • Recruit, interview, and participate in hiring decisions for new Medical Directors. • Lead and coordinate onboarding, orientation, training, shadowing, and competency development activities for newly hired Medical Directors. • Maintain onboarding, training, credentialing, and competency documentation to support URAC, NCQA, and organizational requirements. • Manage Medical Director schedules, PTO requests, coverage planning, and staffing assignments to ensure operational continuity. • Conduct performance evaluations and provide ongoing coaching, mentoring, and professional development. • Monitor Medical Director productivity, decision quality, turnaround times, and documentation accuracy. • Lead Medical Director clinical rounds and facilitate clinical calibration discussions. • Arrange and monitor inter-rater reliability (IRR) activities and physician quality reviews. • Collaborate with Quality and Operations teams to develop quality scorecards, identify performance trends, and implement targeted improvement plans. • Support employee relations activities and physician engagement initiatives in partnership with Human Resources. • Structure and delegate Medical Director pod alignment and responsibilities based on organizational needs, growth, and client demands. • Serve as the senior escalation resource for complex clinical reviews, quality concerns, and physician consultation. Utilization Management Operations and Clinical Oversight (50%) • Conduct high-cost claimant (HCC) reviews and complex case reviews to ensure appropriate utilization and achievement of client commitments. • Identify gaps in care, utilization trends, and opportunities for intervention through clinical review activities. • Support intensive case management strategies for high-risk and medically complex members. • Serve as a clinical subject matter expert for utilization management operations across the organization. • Render utilization review determinations for prior authorization, concurrent review, and other medical necessity reviews based on evidence-based criteria and clinical judgment. • Review and issue denial determinations when requested services do not meet established criteria and clinical standards. • Provide clinical consultation and guidance to nurses, care coordinators, and other interdisciplinary team members. • Support chronic disease management and member engagement initiatives through clinical consultation and review. • Participate in intra-organizational referrals and multidisciplinary case discussions. • Initiate procedural and operational improvements to address recurring utilization management issues and improve efficiency. • Evaluate clinical and utilization data to identify trends, risks, and opportunities for improved member outcomes and operational performance. • Conduct peer-to-peer discussions with requesting and treating providers as appropriate. • Review and render appeal determinations when independent physician review is required. Client, Quality, Audit, and Strategic Leadership (20%) • Support client retention and growth by serving as a clinical resource for client-facing meetings, audits, and strategic initiatives. • Provide sales and business development support in collaboration with the Chief Medical Officer and SVP of Utilization Management. • Support development and enhancement of clinical products, programs, and external-facing solutions. • Serve as a subject matter expert for clinical product development and innovation initiatives. • Lead and support internal and external clinical audit activities, ensuring compliance with regulatory, accreditation, and client requirements. • Collaborate with Quality, Operations, Product, and Executive Leadership teams to identify and implement process improvement opportunities. • Support organization-wide clinical governance, quality improvement, and accreditation readiness efforts. • Build and maintain a high-performing physician culture focused on quality, service excellence, and member outcomes. • Provide strategic support and special project leadership on behalf of the SVP of Utilization Management and Chief Medical Officer. Skills and Qualifications Qualifications Education & Licensure • Hold a current, valid, and unrestricted license to practice medicine that is recognized in the relevant jurisdiction(s); ability to obtain and maintain multistate licensure as required. • Be a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO). • Board certification in primary specialty required. • Maintain licensure of a type and scope that permits the application of independent clinical judgment to evaluate member needs and render utilization review determinations. • Any license restriction permitted by a jurisdiction must be reviewed and approved by the organization and must not impair the ability to perform Medical Director or clinical peer review responsibilities. • Be knowledgeable of the clinical issues under review, including applicable medical or behavioral health conditions, procedures, treatments, and services. • Demonstrate familiarity with current, evidence-based clinical guidelines, standards of care, and relevant emerging or novel treatments. • Be qualified to render clinical opinions and utilization review determinations, as determined by organizational leadership, and perform reviews within the scope of licensure and professional practice. • Function under and provide oversight consistent with Medical Director responsibilities for utilization management activities. Experience • Minimum eight (8) years of progressively responsible clinical practice experience, including three (3) years of formal leadership experience preferred. • Minimum three to five (3 - 5) years of physician clinical review experience, preferably within a commercial health plan or utilization management setting. Skills & Competencies • Remote with Travel to HQ – 25% • Strong knowledge of utilization management principles, national evidence‑based criteria sets (InterQual, MCG), and UM regulatory requirements. • Familiarity with the U.S. healthcare delivery system, standards of care, and current clinical guidelines. • Excellent written and verbal communication skills, including clear and concise clinical documentation. • Collaborative, team‑oriented mindset with the ability to work effectively across disciplines. • Experience supporting regulatory, accreditation, client, or delegated-entity audits. • Experience using clinical and operational data to manage physician quality, productivity, timeliness, and decision consistency. • Demonstrated executive- and client-facing communication skills. • Protect and take care of our company and member’s data every day by committing to work within our company ethics and policies What’s in it for you: Compensation: Competitive base and incentive compensation Coverage: Health, vision and dental featuring our best-in-class healthcare navigation services, along with life insurance, legal and identity protection, adoption assistance, EAP, Teladoc services and more. Retirement: 401(k) plan with up to 4% employer match and full vesting on day one. Balance: Paid Time Off (PTO), 7 paid holidays, parental leave, volunteer days, paid sabbaticals, and more. Development: Tuition reimbursement up to $5,250 annually, certification/continuing education reimbursement, discounted higher education partnerships, paid trainings and leadership development. Culture: Recognition as a Best Place to Work for 15+ years, dedication to diversity, philanthropy and sustainability, and people-first values that drive every decision. Environment: A modern workplace with a casual dress code, open floor plans, full-service dining, free snacks and drinks, complimentary 24/7 fitness center with group classes, outdoor walking paths, game room, notary and dry-cleaning services and more! What you should know: Internal Associates: Already a Healthcare Warrior? Apply internally through Lever Process: Application > Recruiter Video Interview > Online Assessment(s) > Interview(s) > Offer > Background Check. Diversity, Equity and Inclusion: Quantum Health welcomes everyone. We value our diverse team and suppliers, we’re committed to empowering our ERGs, and we’re proud to be an equal opportunity employer . Tobacco-Free Campus: To further enable the health and wellbeing of our associates and community, Quantum Health maintains a tobacco-free environment. The use of all types of tobacco products is prohibited in all company facilities and on all company grounds. Compensation Ranges: Compensation details published by job boards are estimates and not verified by Quantum Health. Details surrounding compensation will be disclosed throughout the interview process. Compensation offered is based on the candidate’s unique combination of experience and qualifications related to the position. 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