Medical Director

• Provide benefit coverage determinations based on medical necessity and contract language
• Review clinical documentation using medical policy criteria, guidelines, and member contracts
• Support clinical programs including disease management and case management
• Support pre-service, post-service, concurrent facility-based care, and transitions between levels of care reviews
• Make final coverage decisions based on medical necessity, investigational status, contractual exclusions, or network structure
• Use clinical expertise to support claims review decisions involving level of care, pricing, complexity assessment, dependent disability status, and by-report procedure payment determinations
• Support peer-to-peer discussions with external physicians and providers regarding denial determinations and collect additional clinical history
• Consult with nursing and clinical staff regarding care options for members in clinical programs
• Participate in development, annual review, and approval of company medical review criteria through the Premera Medical Policy Committee
• Support ongoing education for clinicians involved in medical review
• Provide professional consultation to Premera Blue Cross and contracted practitioners/facilities
• Participate in the Inter-Rater Review process to ensure consistency in clinical decision-making
• Comply with applicable federal, state, and accreditation regulations and standards
• Complete continuing education and participate in ongoing education and training

Assistant Medical Director – Utilization Review

• Provide strategic clinical oversight and day-to-day operational support to community clinical leaders and field teams across Tacoma, Olympia, and Federal Way
• Implement and maintain community clinical policies and procedures
• Conduct regular clinical quality audits through site visits and healthcare-area audits
• Ensure compliance with Brookdale standards and state regulations, resident assessments, staffing, training, and quality assurance
• Provide written audit reports and ensure risk action plans are implemented
• Analyze community models to support clinical staffing based on community size and resident services
• Support quality care delivery and develop medical professional relationships and value-based provider alignment
• Oversee community survey readiness and regulatory compliance
• Monitor quality metrics and clinical outcomes involving falls, elopements, medication administration, psychotropic drug reduction, and skin integrity
• Support infection control, risk management, incident analysis, root-cause analysis, and corrective action plans
• Verify Community Care Conferences and Collaborative Care Processes are in place
• Review resident clinical assessments and validate documentation of services
• Ensure the CARE process addresses controllable resident move-outs
• Provide clinical guidance on appropriate levels of care for resident move-ins
• Support resident and family satisfaction related to clinical care
• Promote preferred pharmacy relationships and resident participation of 80% or greater
• Support the Personal Solutions program and affiliated budget goals
• Participate in hiring, training, mentoring, onboarding, and coaching clinical associates
• Analyze resident and medication incident trends and support process improvement efforts

RN District Director – Clinical Services

• Lead, develop, and support a team of Licensed Clinicians and Clinical Supervisors
• Manage up to 12 fully licensed clinicians
• Meet monthly with fully licensed clinicians for clinical, employment, and supervisory support
• Complete employment evaluations and required paperwork
• Manage up to 5 supervisors and meet twice monthly with each supervisor
• Run a two-hour monthly Supervisor Meeting
• Participate in recruitment, hiring, and onboarding of supervisors, licensed clinicians, interns, and associate supervisees
• Sign off on notes, audit files, respond to crises within 24 hours, and ensure high-quality clinical care
• Develop onboarding trainings and materials and address clinical training needs
• Manage clinician time off and employment policies
• Plan, advertise, and execute quarterly staff events
• Schedule and manage weekly Staff Meetings
• Manage scheduling and transfer processes
• Collaborate with the Admin Lead, HR Manager, Scheduler, and Billing Team
• Respond to staff and client feedback and implement changes with the Leadership Team
• Respond to records requests, subpoena requests, and other legal inquiries
• Work with the billing team to become paneled and credentialed with accepted insurances within the first six months
• Spend at least one six-to-eight-hour day on site at the Federal Way office
• Meet with the Owner weekly and run monthly leadership team meetings
• Provide and/or oversee family and couples therapy
• Support remote and in-office clinicians and strengthen team culture and clinical operations

Medical Director jobs in Washington

Assistant Medical Director – Utilization Review

RN District Director – Clinical Services

Clinical Director, LMFT, LMHC, LICSW, PsyD