Medical Director

About The Role

The Medical Director performs utilization review and medical necessity determinations for BHPS-administered self-funded commercial plans, and supports the Chief Medical Officer in maintaining the quality, consistency, and defensibility of the department’s clinical decisions. Clinical review is the core of the position; committee, education, and client-facing responsibilities are built around a standing review assignment.
* This is a Remote Role

• Renders medical necessity determinations across pre-service, concurrent, and post-service review within regulatory and contractual turnaround requirements.
• Applies MCG care guidelines, client-specific criteria, and BHPS medical policy consistently, selecting the correct criteria source for the member’s plan and documenting rationale that is defensible on appeal, external review, and audit.
• Conducts peer-to-peer discussions with attending and treating physicians regarding admissions, continued stay, level of care, site of service, and contested coverage decisions.
• Reviews and adjudicates appeals for denied services in accordance with plan documents and applicable ERISA and state standards; does not serve as the ERISA appeals fiduciary.
• Communicates certification and non-certification decisions to nurse reviewers within time frames required by URAC, NCQA, ERISA, NYS Article 49, and other applicable state mandates.
• Serves as clinical resource and escalation point for nurse reviewers on complex or criteria-silent cases, providing supporting clinical literature and written rationale.
• Provides clinical input on member and provider grievances and reviews complaint resolution outcomes with the Grievance Coordinator.
• Participates in long-length-of-stay rounds and complex case conferences with Case Management to align level-of-care decisions with the member’s clinical course and discharge plan.
• Participates in the department’s inter-rater reliability testing, case audits, and reviewer calibration sessions, and supports consistent criteria application across reviewers and client books of business.
• Assists in developing and maintaining medical policy, clinical review procedure, and the clinical content of the UM Program Description and annual program evaluation, in conjunction with the CMO.
• Serves as a physician member of the Provider Credentialing Committee (PCC), Clinical Programs Quality Committee (CPQC), UM Committee, and Quality Committee as assigned.
• Supports URAC and NCQA accreditation activity and client and health-plan delegation audits, including file review readiness and corrective action follow-through.
• Delivers clinical education to physician and nurse reviewers, non-clinical staff, and network providers on criteria application, medical policy updates, and documentation expectations.
• Represents Medical Management in client-facing meetings with self-funded employers, brokers, and health-plan partners, and responds to clinically escalated cases.
• Serves as clinical subject-matter expert for Medical Management workflow and technology initiatives, including UM platform configuration and evaluation of clinical decision-support tools.
• Maintains clinical currency through continuing medical education and maintenance of licensure and board certification.
• Adheres to all BHPS policies and procedures and promotes a positive, collaborative work environment.
• The Medical Director provides clinical mentorship and day-to-day guidance to nurse reviewers and intake staff, serves as a peer resource to other Medical Directors, and may be designated by the Chief Medical th Officer to lead specific clinical quality, audit, or education initiatives.

• MD or DO degree with active, unrestricted state medical licensure;
  New York licensure required or obtainable.
• Current ABMS (or AOA equivalent) board certification, maintained throughout employment.
• Minimum 5 years of post-training clinical practice in an office, hospital, or academic setting.
• Minimum 2 years of utilization review or medical director experience at a health plan, TPA, managed care organization, or delegated medical group.
• Hands-on experience applying MCG or comparable evidence-based criteria and writing adverse determination rationale.

• Board certification in Internal Medicine or an Internal Medicine subspecialty.
• Experience in a self-funded commercial or TPA environment.
• Participation in a URAC or NCQA accreditation survey or client delegation audit.
• CPE, MBA, MHA, or comparable…