Medical Director Clinical Development Jobs in Raleigh, NC

• Renders medical necessity determinations across pre-service, concurrent, and post-service review within regulatory and contractual turnaround requirements.
• Applies MCG care guidelines, client-specific criteria, and BHPS medical policy consistently, selecting the correct criteria source for the member’s plan and documenting rationale that is defensible on appeal, external review, and audit.
• Conducts peer-to-peer discussions with attending and treating physicians regarding admissions, continued stay, level of care, site of service, and contested coverage decisions.
• Reviews and adjudicates appeals for denied services in accordance with plan documents and applicable ERISA and state standards; does not serve as the ERISA appeals fiduciary.
• Communicates certification and non-certification decisions to nurse reviewers within timeframes required by URAC, NCQA, ERISA, NYS Article 49, and other applicable state mandates.
• Serves as clinical resource and escalation point for nurse reviewers on complex or criteria-silent cases, providing supporting clinical literature and written rationale.
• Provides clinical input on member and provider grievances and reviews complaint resolution outcomes with the Grievance Coordinator.
• Participates in long-length-of-stay rounds and complex case conferences with Case Management to align level-of-care decisions with the member’s clinical course and discharge plan.
• Participates in the department’s inter-rater reliability testing, case audits, and reviewer calibration sessions, and supports consistent criteria application across reviewers and client books of business.
• Assists in developing and maintaining medical policy, clinical review procedure, and the clinical content of the UM Program Description and annual program evaluation, in conjunction with the CMO.
• Serves as a physician member of the Provider Credentialing Committee (PCC), Clinical Programs Quality Committee (CPQC), UM Committee, and Quality Committee as assigned.
• Supports URAC and NCQA accreditation activity and client and health-plan delegation audits, including file review readiness and corrective action follow-through.
• Delivers clinical education to physician and nurse reviewers, non-clinical staff, and network providers on criteria application, medical policy updates, and documentation expectations.
• Represents Medical Management in client-facing meetings with self-funded employers, brokers, and health-plan partners, and responds to clinically escalated cases.
• Serves as clinical subject-matter expert for Medical Management workflow and technology initiatives, including UM platform configuration and evaluation of clinical decision-support tools.
• Maintains clinical currency through continuing medical education and maintenance of licensure and board certification.
• Adheres to all BHPS policies and procedures and promotes a positive, collaborative work environment.
• The Medical Director provides clinical mentorship and day-to-day guidance to nurse reviewers and intake staff, serves as a peer resource to other Medical Directors, and may be designated by the Chief Medical thOfficer to lead specific clinical quality, audit, or education initiatives.

• MD or DO degree with active, unrestricted state medical licensure; New York licensure required or obtainable.
• Current ABMS (or AOA equivalent) board certification, maintained throughout employment.
• Minimum 5 years of post-training clinical practice in an office, hospital, or academic setting.
• Minimum 2 years of utilization review or medical director experience at a health plan, TPA, managed care organization, or delegated medical group.
• Hands-on experience applying MCG or comparable evidence-based criteria and writing adverse determination rationale.

• Board certification in Internal Medicine or an Internal Medicine subspecialty.
• Experience in a self-funded commercial or TPA environment.
• Participation in a URAC or NCQA accreditation survey or client delegation audit.
• CPE, MBA, MHA, or comparable physician-leadership or management credential.
• Teaching, precepting, or curriculum development experience.

• Working knowledge of URAC, NCQA, ERISA, CMS, and state utilization review and appeals regulation, including New York requirements.
• Strong medical record review, evidence appraisal, and clinical policy interpretation skills.
• Ability to write clear, member-readable determination rationale that withstands appeal and audit.
• Sound, timely, independent clinical judgment under turnaround time pressure.
• Effective verbal and written communication with physicians, staff, members, and client and broker audiences.
• Proficiency with UM or EHR platforms and standard business software (Microsoft Office; reporting tools such as Excel or Tableau).

• Occasional travel for client meetings, provider engagement, and company or committee meetings.
• Coverage of urgent and expedited review requests may be required outside standard business hours on a rotating basis.

About
At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities.
Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes, and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.
Come be a part of the Brightest Ideas in Healthcare™.
Company Mission
Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.
Company Vision
Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
DEI Purpose Statement 
At BHPS, we encourage all team members to bring your authentic selves to work with all your unique abilities.   We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace.  We are building, nurturing, and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.
*We are an Equal Opportunity Employer
JOB ALERT FRAUD:  We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information.  Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section.  If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: recruiting@brightonhps.com

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