Medical Director

• Serve as the senior physician executive for the health plan
• Lead all Medical Directors and UM staff members, including clinicians and other clinical staff reviewers
• Provide clinical leadership across affordability, quality, utilization, access, member outcomes, population health, and provider engagement
• Advise executive leadership on clinical risk, utilization trends, medical cost drivers, medical policy, provider behavior, and quality improvement opportunities
• Represent the health plan in physician, provider, regulatory, and delivery system forums
• Serve as the accountable clinical leader for UM medical necessity decision-making
• Oversee adverse determinations, peer-to-peer review, appeals, reconsiderations, clinical escalation pathways, and physician reviewer consistency
• Ensure UM decisions are evidence-based, timely, fair, well-documented, and aligned with applicable requirements
• Maintain clinical oversight of criteria, medical necessity rationale, denial language, decision consistency, and reviewer performance
• Partner with the Healthcare Value Leader to ensure UM operations support timely and compliant clinical decisions
• Own clinical governance for medical policies, clinical criteria, practice guidelines, and evidence-based care standards
• Provide clinical leadership for coverage policy interpretation, new technology review, and emerging clinical practice changes
• Provide clinical guidance for case management, disease management, transitions of care, high-risk member programs, and population health initiatives
• Participate in complex case escalation, avoidable utilization review, post-acute strategy, and clinical intervention design
• Review medical cost and utilization trends with the Healthcare Value Leader, Finance, Actuarial, Analytics, and Network
• Lead initiatives related to inpatient utilization, ED utilization, post-acute care, specialty variation, site-of-care optimization, pharmacy trends, and avoidable admissions
• Support development of clinical interventions that reduce unnecessary utilization while preserving access and quality
• Serve as the health plan’s senior clinical representative to physicians, provider groups, and delivery system leaders
• Lead physician-to-physician conversations on medical necessity, utilization variation, care standards, documentation, quality improvement, and value-based performance
• Support provider education related to clinical criteria, medical policies, UM expectations, appeals, and evidence-based practice
• Partner with Quality, Behavioral Health, and Risk Adjustment leadership on clinical strategy, quality, risk adjustment, behavioral health integration, equity, accreditation, and regulatory requirements
• Provide clinical support for HEDIS, Stars or equivalent quality programs, care gap closure, chronic disease management, and clinical quality initiatives

Medical Director jobs in New Mexico

Chief Medical Officer – Health Plan