Medical Director

• Provide medical leadership and support on medical and regulatory matters
• Oversee physician review, utilization review, quality assurance, and case management
• Develop and implement medical policies and standards
• Evaluate new technologies and treatments
• Identify medical and pharmacy cost and utilization trends and recommend solutions
• Provide clinical oversight for behavioral health activities across utilization management, care coordination, quality, and population health for South Carolina Medicaid
• Align Healthy Blue’s behavioral health strategy with SCDHHS priorities and statewide goals
• Make defensible, evidence-based utilization decisions and review complex and high-cost cases
• Partner with program integrity teams to identify inappropriate utilization patterns
• Lead integrated behavioral health/medical models, suicide prevention, crisis response, and transitions-of-care strategies
• Advance health equity across South Carolina’s rural and urban regions
• Lead clinical teams and operations to improve compliance, efficiency, and communication
• Support Payment Integrity units by analyzing abuse patterns and recommending solutions
• Oversee quality improvement and health plan and medical program accreditations
• Develop quality initiatives and provide clinical support and network outreach
• Perform physician review for utilization management, appeals, and case management
• Research new or controversial medical procedures and technologies
• Educate staff, network providers, and the medical community on medical policy and program administration

Medical Director jobs in South Carolina

Behavioral Health Medical Director