Medical Director

POSITION: Medical Director
DEPARTMENT: Administration
POSITION SUMMARY:
The Medical Director provides strategic clinical oversight for the health plan, ensuring appropriateness, medical necessity, and quality of care delivered to members. This role guides all major clinical program components including Utilization Management (UM), Quality Assessment and Performance Improvement (QAPI), credentialing, pharmacy, population health, and provider engagement. The Medical Director supports regulatory compliance, drives performance improvement initiatives, and acts as a liaison between clinical operations, providers, and leadership.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.

2. Provide clinical oversight for all major UPHP clinical program components, including Utilization Management (UM), Pharmacy, Quality, Care Management, Credentialing, and Population Health programs.

3. Ensure timely and appropriate medical decision-making, including availability for after-hours consultation when necessary. Provide clinical guidance to utilization management and appeals team members regarding authorizations, denials, and appeals.

4. Oversee and manage the Quality Assessment and Performance Improvement (QAPI) Program, ensuring compliance with federal, state, and accreditation standards.

5. Participate in and lead UPHP clinical committees, including serving as chair for the Credentialing Committee, Clinical Advisory - Utilization Management Committee (CA-UMC), and other internal and external working groups.

6. Collaborate with the Chief Quality Officer to develop and lead clinical population health program strategies and quality improvement initiatives related to disease management, prevention, health literacy, and health equity interventions. Act as physician champion of such initiatives to support UPHP provider network's participation in ongoing quality improvement.

7. Review the medical necessity and appropriateness of services through pre-authorization, post-service appeals, and grievance reviews.

8. Ensure medical decisions are based on evidence-based standards and not influenced by fiscal or administrative considerations.

9. Ensure provider performance aligns with medical standards, including monitoring practice patterns, conducting retrospective reviews, and supporting corrective actions.

10. Review clinical components of provider contracts and contribute to provider performance evaluations and quality incentive programs.

11. Coordinate with the Compliance Officer on identification and reporting of potential Fraud, Waste, and Abuse (FWA).

12. Ensure compliance with mandated reporting requirements, including communicable diseases, child abuse, and neglect per state and local laws.

13. Provide clinical support to the Pharmacy Department, including coordination with the PBM and review of pharmacy utilization trends.

14. Engage with providers and medical groups to foster positive relationships, discuss utilization trends, and support resource management.

15. Monitor continuity and quality of care across care settings (e.g., hospitals, skilled nursing facilities, and home care).

16. Participate in policy development, including medical protocols, clinical guidelines, and administrative procedures affecting member care.

17. Serve as the UPHG Physician Organization (PO) Medical Director; provide clinical leadership of programs for the UPHG and serve as a liaison between the PO member physicians and PO administration, including insights into healthcare quality, appropriate utilization, and engagement in Physician Group Incentive Program (PGIP) clinical initiatives.

18. Serve as a clinical advisor to leadership, contributing to strategic planning, regulatory readiness, and interdepartmental collaboration.

19. Maintain confidentiality of all member and provider data and uphold ethical standards in all clinical and operational activities.

20. Performs other related duties as assigned or requested.

POSITION QUALIFICATIONS:
Education:
Doctorate Degree in Medicine (MD or DO)

Preferred Education:
Board Certified (Strong preference for: Family Medicine, Emergency Medicine, Internal Medicine, or Pediatrics)

Other Requirements:

Active, unrestricted physician license in the State of Michigan
In good standing with no sanctions from Medicare or Medicaid

Minimum Experience:
Five (5) years of direct clinical practice

Three (3) years utilization review, quality improvement, or care management leadership

Preferred Experience:
Experience as a Medical Director, and in peer review, provider contracting, and medical policy development
Experience in managed care/HMO setting
Experience with data analysis to improve health care outcomes.

Knowledge:
Strong understanding of NCQA, HEDIS measures, and QAPI program requirements
Deep knowledge of Medicaid, Medicare, and state-specific healthcare regulations
Familiarity with pharmacy benefit management (PBM) processes and integration into managed care
Understanding of value based payment programs and risk adjustment models and their impact on population health
strategies
Well-versed in applying evidence-based clinical guidelines to improve quality and outcomes.
Knowledge of state and federal healthcare laws, including compliance, reporting, and accreditation

Required Skills:
Excellent oral and written communication abilities for cross-functional collaboration and provider engagement
Strong leadership, facilitation, and relationship-building skills, with the ability to lead committees and workgroups effectively
Proficient in data analytics and health IT systems, including performance monitoring, reporting tools, and EMR platforms
Effective organizational and decision-making skills to manage competing priorities and complex clinical oversight functions
Skilled in strategic planning, policy development, and translating clinical goals into operational outcomes

The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job-related selection or promotional criteria.

Physical Requirements:
This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements :

Ability to enter and access information from a computer
Ability to access all areas of the UPHP offices
Occasionally lifts supplies/equipment
Prolonged periods of sitting
Manual dexterity

Working Conditions:
Works in office conditions, but occasional travel may be required
Exposure to situations requiring exceptional interpersonal skills or periods of intense concentration
Subject to many interruptions
Occasionally subjected to irregular hours