Healthy Blue Louisiana

Company Description Healthy Blue Louisiana is a health plan that collaborates closely with the state’s healthcare community to expand access to quality care. In Louisiana, the organization works with more than 13,000 doctors and offers members access to over 160 hospitals. Its network includes the top three hospitals in Louisiana as ranked by U.S. News and World Report, giving members and providers a broad range of specialty and acute care options. Healthy Blue Louisiana focuses on coordinated, person-centered care and strives to improve health outcomes for diverse populations across the state. Clinicians joining the team have the opportunity to influence care quality at scale in a supportive, mission-driven environment.

Role Description This is a full-time, remote role for a Medical Director of Utilization Management who is board certified in Emergency Medicine, Family Medicine, or double board certified in Internal Medicine and Pediatrics. The Medical Director will review and make determinations on medical necessity and appropriateness of services using evidence-based guidelines and health plan policies. This role includes collaborating with physicians, hospitals, and interdisciplinary care teams to support optimal utilization, care coordination, and quality outcomes. The Medical Director will participate in case discussions, peer-to-peer reviews, appeals, and quality improvement initiatives, while helping to develop and refine utilization management protocols. Responsibilities also include contributing clinical expertise to committees, supporting regulatory and accreditation compliance, and providing guidance to internal teams on clinical and coverage issues.

Qualifications

• Strong clinical foundation in Medicine with board certification in Emergency Medicine, Family Medicine, or double board certification in Internal Medicine and Pediatrics.
• Experience collaborating and communicating effectively with physicians and other clinicians, including conducting peer-to-peer reviews and interdisciplinary case discussions.
• Broad clinical understanding and ability to review cases across multiple specialties, such as Cardiology, Neurology, and Oncology, and apply evidence-based criteria.
• Experience or training in utilization management, care management, or health plan/managed care environments is strongly preferred.
• Active, unrestricted medical license (Louisiana license or ability to obtain, as required by the role).
• Demonstrated ability to interpret and apply clinical guidelines, medical policies, and regulatory requirements.
• Excellent analytical, documentation, and decision-making skills, with proficiency in working within electronic systems and clinical review tools.
• Commitment to equitable, patient-centered care and to working effectively with diverse populations and multidisciplinary teams.