HealthAxis Group · 2 months ago
Medical Director, Utilization Management
United States
Full-time
Remote
Lead/Staff, Director/Executive
5+ years expHealthAxis is a prominent provider of core administrative processing system technology and business process outsourcing capabilities to healthcare payers. The Medical Director of Utilization Management will provide medical expertise and decision making within the Utilization Management team, ensuring healthcare services are medically necessary and appropriately utilized while collaborating with various stakeholders for effective healthcare delivery.
Health CareInformation Technology
Responsibilities
Assists in development and maintaining an efficient UM program to meet the needs of the health plan members and commensurate with company values
Educates primary care physicians regarding systems, structures, processes and outcomes necessary for assurance of regulatory compliance related to market activities
Develops strategies for improving all aspects of market performance including RAPS, membership, and medical management
Participates in case reviews and medical necessity determination
Serve as a resource for clinical staff, offering guidance on complex cases and medical necessity
Conducts post service reviews issued for medical necessity and benefits determination coding
Maintains accurate and thorough documentation of activities and decisions
Analyzes aggregate data and reports to primary care physician
Serves as the liaison between physicians and health plan Medical Directors
Performs secondary review when prior authorization, initial and concurrent reviews do not meet medical necessity criteria or level of care appropriateness
Participates in the Grievance and Appeal review process to provide recommendations
Utilize clinical expertise to identify the salient points within a case review
Identify process improvements opportunities and inefficiencies
Interact with external physicians as needed – through secure messaging, text, and potential phone calls
Opportunity to be involved in additional responsibilities such as special projects, focus groups, new Medical Director training, or organizational committees
Collaborate with management and operations team members to propose strategic, operational, and technological solutions for improving quality
Other duties as assigned
Qualification
Required
Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) degree
Unrestricted licensed in at least one state within the United States
5+ years of clinical practice experience
2+ years of experience in utilization management activities
Proficiency with Microsoft Office applications
M.D or D.O and five (5) years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry
Board Certified in an American Board of Medical Specialties Board, and an active, unrestricted license to practice medicine in a state or territory of the United States
Previous experience with administrative oversight of the medical function of an insurance (or related) company
Previous experience leading a team of professionals
A strong perspective on how to increase operational excellence and automation through process improvement and technology partnerships
Strong interpersonal skills, with the ability to regularly interact with various client departments/project teams
An ability to balance critical thinking with hands-on execution. Forward-thinking strategic leader
Results-driven. Ability to work in a fast-paced and changing environment and react professionally under pressure
Self-starter with strong organizational skills. Excellent oral and written communication skills
Preferred
Preferably, Board Certified Family Practitioner or Internal Medical Specialist
Company
HealthAxis Group
HealthAxis Group seeks to reboot healthcare as a completely efficient, information-driven, and cooperative institution.
201-500 employees
H1B Sponsorship
HealthAxis Group has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2024 (1)
2023 (10)
2022 (3)
2021 (8)
2020 (14)
Funding
Current Stage
Growth StageTotal Funding
$57MKey Investors
Revelstoke Capital PartnersBrown Simpson Asset Management
2022-01-18Private Equity
1999-12-08Private Equity· $57M
Leadership Team
Matthew Hughes
Chief Executive Officer
Chris House
Chief Technology Officer
Recent News
2025-12-16
2025-06-06
Company data provided by crunchbase