Job Description

Medical Director, Quality & Health Services

Summary:

We are seeking a dynamic and experienced physician leader to oversee all clinical aspects of our Quality Management Program. This role works closely with the CEO and the Quality Management Steering Committee (QMSC) to ensure the delivery of high-quality, medically necessary, and cost-effective care. The Medical Director provides strategic and clinical leadership across Health Services programs including Case Management, Disease Management, Utilization Management, Credentialing, Pharmacy Services, and Appeals & Grievances. This position also plays a key role in regulatory compliance, provider engagement, and quality improvement initiatives aligned with CMS, accreditation, and state/federal guidelines.

Key Responsibilities:

Lead the clinical strategy and operations of the Quality Management Program. Provide clinical oversight and guidance for Case Management, Disease Management, and Utilization Management programs. Ensure all clinical decisions are evidence-based, medically necessary, and aligned with regulatory standards. Conduct peer clinical reviews and make final determinations on complex or non-certifiable cases. Chair key committees including the Medical Advisory Committee, Credentialing Committee, and Peer Review Committee. Collaborate with providers to build and maintain a high-performing, quality-driven network. Review and approve clinical review criteria and screening tools annually. Participate in weekly rounds with Utilization Review Nurses to address complex cases. Support the development and implementation of quality improvement projects and clinical performance measures. Oversee delegated clinical functions and ensure compliance with accreditation standards. Serve as a clinical liaison for government programs and regulatory bodies (e.g., CMS, HEDIS). Respond to provider and member complaints, and recommend system improvements. Maintain timely communication regarding licensure or certification changes.

Qualifications:

M.D. or D.O. from an AMA-accredited medical school. Active, unrestricted Florida medical license and board certification. Minimum 5 years of clinical practice experience. At least 10 years of progressive leadership in Managed Care and Medicare Advantage plans. Proven experience with HEDIS, IPA models, and health plan operations. Strong knowledge of CMS, NCQA, and state regulatory requirements. Experience in peer review, credentialing, and appeals/grievance processes.

Core Competencies:

Strategic and analytical thinking with a focus on quality and compliance. Strong interpersonal and communication skills to engage with providers and internal teams. Leadership in change management, innovation, and cross-functional collaboration. Ability to interpret complex clinical data and drive performance improvement. Commitment to excellence, integrity, and continuous learning.

Additional Information:

Travel required for provider engagement and site visits. Must meet ongoing continuing education and licensure requirements.
We offer competitive compensation and benefits packages for qualified candidates. Join our team of dedicated healthcare professionals and make a difference in the lives of patients. Apply now!

Job Type: Full-time

Pay: From $230,000.00 per year

Benefits:

401(k) Dental insurance Health insurance Life insurance Paid time off Vision insurance
Work Location: In person