Overview The Medical Director will lead the Medical areas of the company, including Precertification, Case Management, and Patient Services, to develop a scalable operational platform that ensures members receive optimal medical care within policy guidelines and delivers superior service. The ideal candidate must have excellent communication and interpersonal skills, along with the ability to manage multiple projects and implement high-quality work processes. ESSENTIAL JOB DUTIES AND RESPONSIBILITIES 1. Establish and ensure the consistent application of the company's medical strategy across all medical areas. 2. Lead the development and execution of high-quality, standardized work processes through internal training and continuous improvement initiatives. 3. Review and approve high-cost services such as air ambulance, transplants, chemotherapy, and radiation treatments. 4. Perform benefit-driven medical necessity reviews for coverage, case management, and claims resolution, utilizing benefit plan information, clinical guidelines, and best practices. 5. Understand internal operations deeply to review and optimize processes, achieving efficiency and cost reductions. 6. Promote and implement sound medical decision-making practices to enhance service quality. 7. Define key performance indicators and oversee the department’s budget and staffing requirements. 8. Collaborate with the Actuary for ongoing evaluation and updating of standards, guidelines, and best practices. 9. Ensure the consistent application of medical guidelines. 10. Participate in or develop medical distinction programs. 11. Deliver exceptional service to internal and external stakeholders. 12. Develop staffing and resource models to balance workloads and keep teams well-informed. 13. Contribute to policy review processes, proposing changes from a medical perspective. 14. Build and maintain relationships with agents, communicating via calls, emails, seminars, and conventions as appropriate. 15. Work closely with various business areas, including Client Services, Operations, Providers, Actuarial, Legal, Marketing, and Sales. 16. Manage the Case Management process to meet performance standards and procedural guidelines. 17. Oversee cost-control activities, including negotiation strategies, monitoring savings, and establishing UCR guidelines. 18. Lead the medical audit team and facilitate collaboration between audit and other Precertification teams. 19. Act as a coach and motivator, providing support, guidance, and training to staff. 20. Lead internal educational programs to improve knowledge, service, and productivity. 21. Supervise the on-call process, defining requirements and support needs. 22. Set approval levels for different case types and establish overtime criteria, including staff qualifications and approval processes. 23. Research, propose, and approve tools to enhance productivity and medical data accuracy. Qualifications DESIRED MINIMUM QUALIFICATIONS - Strong knowledge of medical conditions and their potential cost impacts. - Deep understanding of managed care policies and principles. - Ability to assess risks and potential downsides in claims decisions. - Experience leading cross-functional teams. - Knowledge of change management principles. - Strong analytical skills and attention to detail. - Ability to work independently with excellent time management and prioritization skills. - Excellent public speaking and presentation skills. - Commitment to service quality. - Bilingual proficiency in English and Spanish; Portuguese skills are a plus. - Familiarity with health insurance principles and guidelines, including Milliman guidelines. EDUCATION AND EXPERIENCE - Minimum of 10 years of medical experience in hospitals or health insurance companies, preferably with international major medical products. - At least 5 years of management experience or equivalent project implementation experience. - Proven track record of leading teams to deliver superior service in a fast-paced, entrepreneurial environment. - Medical Doctor degree (U.S. or foreign). #J-18808-Ljbffr