Overview The Medical Director will lead the Medicalareas of the company, including Precertification, Case Management,and Patient Services, to develop a scalable operational platformthat ensures members receive optimal medical care within policyguidelines and delivers superior service. The ideal candidate musthave excellent communication and interpersonal skills, along withthe ability to manage multiple projects and implement high-qualitywork processes. ESSENTIAL JOB DUTIES AND RESPONSIBILITIES 1.Establish and ensure the consistent application of the company'smedical strategy across all medical areas. 2. Lead the developmentand execution of high-quality, standardized work processes throughinternal training and continuous improvement initiatives. 3. Reviewand approve high-cost services such as air ambulance, transplants,chemotherapy, and radiation treatments. 4. Perform benefit-drivenmedical necessity reviews for coverage, case management, and claimsresolution, utilizing benefit plan information, clinicalguidelines, and best practices. 5. Understand internal operationsdeeply to review and optimize processes, achieving efficiency andcost reductions. 6. Promote and implement sound medicaldecision-making practices to enhance service quality. 7. Define keyperformance indicators and oversee the department’s budget andstaffing requirements. 8. Collaborate with the Actuary for ongoingevaluation and updating of standards, guidelines, and bestpractices. 9. Ensure the consistent application of medicalguidelines. 10. Participate in or develop medical distinctionprograms. 11. Deliver exceptional service to internal and externalstakeholders. 12. Develop staffing and resource models to balanceworkloads and keep teams well-informed. 13. Contribute to policyreview processes, proposing changes from a medical perspective. 14.Build and maintain relationships with agents, communicating viacalls, emails, seminars, and conventions as appropriate. 15. Workclosely with various business areas, including Client Services,Operations, Providers, Actuarial, Legal, Marketing, and Sales. 16.Manage the Case Management process to meet performance standardsand procedural guidelines. 17. Oversee cost-control activities,including negotiation strategies, monitoring savings, andestablishing UCR guidelines. 18. Lead the medical audit team andfacilitate collaboration between audit and other Precertificationteams. 19. Act as a coach and motivator, providing support,guidance, and training to staff. 20. Lead internal educationalprograms to improve knowledge, service, and productivity. 21.Supervise the on-call process, defining requirements and supportneeds. 22. Set approval levels for different case types andestablish overtime criteria, including staff qualifications andapproval processes. 23. Research, propose, and approve tools toenhance productivity and medical data accuracy. QualificationsDESIRED MINIMUM QUALIFICATIONS - Strong knowledge of medicalconditions and their potential cost impacts. - Deep understandingof managed care policies and principles. - Ability to assess risksand potential downsides in claims decisions. - Experience leadingcross-functional teams. - Knowledge of change managementprinciples. - Strong analytical skills and attention to detail. -Ability to work independently with excellent time management andprioritization skills. - Excellent public speaking and presentationskills. - Commitment to service quality. - Bilingual proficiency inEnglish and Spanish; Portuguese skills are a plus. - Familiaritywith health insurance principles and guidelines, including Millimanguidelines. EDUCATION AND EXPERIENCE - Minimum of 10 years ofmedical experience in hospitals or health insurance companies,preferably with international major medical products. - At least 5years of management experience or equivalent project implementationexperience. - Proven track record of leading teams to deliversuperior service in a fast-paced, entrepreneurial environment. -Medical Doctor degree (U.S. or foreign).#J-18808-Ljbffr