Title: Medical Director
Location: Washington DC-Baltimore Area
Base: $158,129.00/yr - $213,538.00/yr
The Funds Medical Director provides clinical strategy and operational guidance for health-related programs, ensuring medical necessity accuracy, regulatory compliance, and expert consultation. The role involves collaboration with internal and external stakeholders, policy development, program innovation, and serving as a clinical standards subject matter expert. Responsibilities include oversight of medical management contractors, medical policy interpretation, and participation in committees such as Pharmacy and Therapeutics.
Added on: 08/08/2025
About this role
The Funds Medical Director is an individual contributor that plays a pivotal role in guiding the clinical strategy and operational execution of health-related programs. Leveraging a strong medical background and analytical expertise, the Funds Medical Director evaluates complex clinical scenarios, ensures regulatory compliance, and provides expert consultation on medical necessity and standards of care. This role involves active collaboration with internal teams, external providers, and other stakeholders to support high-quality, compassionate, and cost-effective care for Funds beneficiaries. The Funds Medical Director also contributes to program development, policy innovation, and serves as a subject matter expert in clinical standards and population health. The Medical Director champions the clinical direction of all health-related programs, working collaboratively with Field Health management and departmental leadership, and under the guidance of the Executive Director and the Funds’ Trustees. Success in this role requires a balance of clinical insight, strategic thinking, and collaborative leadership to advance the Funds’ mission and improve health outcomes for our beneficiaries.
Core Responsibilities
Responsible for ensuring the clinical accuracy of all organization determinations and reconsiderations involving medical necessity. Provide oversight and guidance to the medical directors at the medical management and pharmacy benefit contractors and subcontractors providing services to the Funds' health care programs.
Serves as a subject matter expert on clinical standards of care; reviews medical issues in the resolution of disputes (RODs). As requested by Funds Leadership and the Funds’ Trustees, provides medical opinions informed by thorough research into the prevailing standards of care and the current state of medical science, to support informed decision-making.
Partner with stakeholders to advance Funds priorities through coordinated, beneficiary-centered care and innovative, cost-effective quality initiatives.
Interpret and develop Funds clinical policies and standard operating procedures; ensure clinical accuracy and compliance with medical necessity standards.
Serve as medical liaison with Funds' providers and beneficiaries with respect to programs and procedures associated with the Funds' health care programs.
Serve as co-chair of the Pharmacy and Therapeutics Committee; represent the Funds in internal and external committees.
Serves as a resource on matters regarding medical policy and medical coverage issues for Funds' beneficiaries.
Reviews and evaluates proposals for new medical management and pharmacy benefit management program initiatives for incorporation into the Funds' health care benefit programs.
Ensure compliance with HIPAA and maintain the privacy and security of protected health information. Responsible for adhering to all Funds’ policies and procedures adopted to comply with the Health Insurance Portability and Accountability Act (HIPAA) governing the privacy, security and use of protected health information.
Candidate Requirements
Education and experience: The Medical Director shall be a graduate of an accredited medical school and have at least five (5) years in setting(s) that are relevant to the development and conduct of programs that are relevant to the care of Funds' beneficiaries. Training (MPH or comparable degree) and/or experience in public and population health are desirable. Work in the field of gerontology is also desirable.
Has knowledge of program development and innovation in managed health care programs, including programs to serve the elderly and programs sited in rural settings.
Has a working knowledge of Medicare and other federal and state medical and social services programs that are relevant to Funds' beneficiaries.
Has a working knowledge of current state, local, and national health policy issues.
Certifications/ License Requirements: The Medical Director must be a physician with a current and unrestricted license to practice medicine in a State, Territory, Commonwealth of the United States (that is, Puerto Rico), or the District of Columbia.
COMPLETE BACKGROUND CHECK REQUIRED.
About Us
The Funds is a group of six multiemployer plans that provide pension and health benefits primarily to retired union coal miners and their eligible dependents.