Medical director jobs in Jefferson City, MO - 73 jobs

**Parexel** is in the business of improving the world's health. We do this by providing a suite of biopharmaceutical services that help clients across the globe transform scientific discoveries into new treatments. From clinical trials to regulatory, consulting, and market access, our therapeutic, technical, and functional ability is underpinned by a deep conviction in what we do. We believe in our values, Patients First, Quality, Respect, Empowerment & Accountability. **Parexel is looking for a Medical Director with a very strong background in Ophthalmology to join our Global Medical Sciences team.** **The role can be based remo** t **ely in the US or Canada.** The Medical Director is a medical expert with specialized therapeutic expertise and some experience across indications, clients and drug development. They initiate and maintain medical and consultative relationships with clients, consult on early engagement and pre-award efforts and serve as a medical monitor for contracted projects. The Medical Director may take on leadership roles by participating in initiatives, mentoring junior MDs and/or, where appropriate, managing a team of physicians. Primary activities will focus on **Medical Monitoring Delivery & PV Support** . The medical monitor will independently deliver all medical support required for successful delivery of the projects according to contracted agreement with the sponsor (i.e., tasks and time per task contracted) and according to the assigned role (Global Lead Physician or Regional Lead Physician). **Medical Expertise** and experience in **Ophthalmology** is essential to the medical monitor role and will be manifested in high quality consultation on protocol development or drug development programs, medical review of various documents, collaboration on internal therapeutic area meetings, training module development, white papers, slide sets, publications etc. **Client Relationship Building & Engagement,** including soliciting and addressing client feedback and suggestions regarding medical study-related activities, are core skills required of the medical monitor. **Business Development:** the medical monitor will provide medical expertise / leadership in Proposal Development Teams (PDTs) for client bid pursuit meetings. **Skills** + Excellent interpersonal skills including the ability to interact well with sponsor/client counterparts + Client-focused approach to work + Excellent time management skills + Excellent verbal and written medical communication skills + Excellent standard of written and spoken English + A flexible attitude with respect to work assignments and new learning + Ability to manage multiple and varied tasks with enthusiasm and prioritize workload with attention to detail + Willingness to work in a matrix environment and to value the importance of teamwork. **Knowledge And Experience** + Experience in clinical medicine (general or specialist qualifications) with Fellowship or specialty training in **Ophthalmology** , which is expected to be kept up to date. + A background in clinical aspects of drug development, including all aspects of Medical Monitoring and study design/execution, preferred + Clinical practice experience + Good knowledge of the drug development process including drug safety, preferred + Experience in Pharmaceutical Medicine, preferred + Experience leading, mentoring and managing individuals/ a team, preferred **Education** + US Board certified in **Ophthalmology** or Canadian equivalent + Experience as a Physician in Industry or as a clinical trial investigator is required + Previous CRO experience is strongly preferred + Medically qualified in an acknowledged medical school with completion of at least basic training in clinical medicine (residency, internship) The ability to travel 15% domestically or internationally is required \#LI-LB1 \#LI-REMOTE EEO Disclaimer Parexel is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to legally protected status, which in the US includes race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

The Medical Director, Rheumatology and/or Dermatology Medical Strategy is a critical role responsible for shaping the strategic processes and planning for assets in early development (e.g., pre-Phase 3) within the Nephrology and Immunology portfolio. This position manages the unique challenge of establishing an emerging portfolio, incorporating newly acquired assets, which requires significant scientific and strategic agility and a strong ability to balance competing priorities. This position reports directly to the Senior Director, Immunology Lead, who in turn reports to the Executive Director, Nephrology & Immunology Lead. **** **Key Responsibilities Include:** **Medical Strategy & Narrative** + Provide key medical input into the initial development of the Target Reimbursable Product Profile as well as early development plans ensuring scientific consistency and alignment across R&D, Clinical, Global Medical Affairs, and Early Commercialization functions + Provide high-quality scientific/clinical input and review of early asset plans, ensuring content aligns with the overarching Medical Narrative + Serve as a primary scientific resource, providing guidance on the disease state and mechanism of action for the early Nephrology and Immunology portfolio helping to translate science into value for patients and stakeholders + Lead the Strategy and Tactical Planning Process, identifying critical data needs for the emerging portfolio **Evidence Generation Process** + Oversee the Medical Evidence Generation Process, translating strategic data gaps into clear research priorities and providing expert input into the design and feasibility of clinical trials and data generation initiatives + Support the planning and execution of Medical Affairs evidence generation activities relevant to early assets **External Stakeholder Engagement** + Identify and engage Medical experts to support collection, curation and communication of clinical Medical and methodological insights to inform understanding of unmet medical needs, emerging standard of care and development opportunities + Develop Key Intelligence Topics & Questions (KITs/KIQs) for relevant assets, serving as the blueprint for insight collection from Medical Experts + Lead the strategic planning, content development, and successful facilitation of consulting activities including Advisory Boards, ensuring objectives align with data gap analyses and asset/portfolio strategy + Lead scientific exchange with Medical Experts to gather insights and validate development hypotheses + Support the development of scientific publications, abstracts, and presentations related to early assets **Cross-functional Integration & Planning** + Collaborate within the Nephrology & Immunology Medical Business Unit with the Nephrology & Immunology Medical Communications and Field Medical Affairs sub-teams + Partner with and serve as a scientific and clinical resource for cross-functional colleagues including Clinical Development, Global Integrated Evidence & Innovation, Regulatory and Global Marketing and Market Access + Support indication prioritization and portfolio planning for early assets + Consider technology and AI to support workflow improvement **Qualifications** **Education and Experience:** + Advanced scientific degree is required (PharmD, MD, PhD, or equivalent) with expertise in **Rheumatology and/or Dermatology** + Preference for previous experience in Clinical Development, Research, or early-stage Medical Affairs + Expertise in Rheumatology or Dermatology is strongly preferred + Experience supporting BD evaluations for potential acquisitions + Experience contributing to the integration and strategic planning for newly acquired or in-licensed assets + Proven experience managing Evidence Generation processes and executing scientific Advisory Boards **Skills and Competencies:** + Motivated and solution-oriented with the ability to work collaboratively across the organization, particularly with R&D and Clinical teams + Strategic agility required to build and adapt scientific strategy for an emerging portfolio + Excellent communication and interpersonal skills, including experience presenting complex development strategies to large internal groups and engaging a limited number of highly specialized external experts + Full understanding of rules and regulations in pharma, with the ability to apply knowledge of guidelines and regulations to early-stage Medical Affairs activities + Ability to work in a fast-paced, dynamic environment, with a proactive and problem-solving mindset + Strong understanding of drug development processes, especially early-stage development + \#LI-PG1 **Competencies** **Accountability for Results -** Stay focused on key strategic objectives, be accountable for high standards of performance, and take an active role in leading change. **Strategic Thinking & Problem Solving -** Make decisions considering the long-term impact to customers, patients, employees, and the business. **Patient & Customer Centricity -** Maintain an ongoing focus on the needs of our customers and/or key stakeholders. **Impactful Communication -** Communicate with logic, clarity, and respect. Influence at all levels to achieve the best results for Otsuka. **Respectful Collaboration -** Seek and value others' perspectives and strive for diverse partnerships to enhance work toward common goals. **Empowered Development -** Play an active role in professional development as a business imperative. Minimum $209,599.00 - Maximum $313,375.00, plus incentive opportunity: The range shown represents a typical pay range or starting pay for individuals who are hired in the role to perform in the United States. Other elements may be used to determine actual pay such as the candidate's job experience, specific skills, and comparison to internal incumbents currently in role. Typically, actual pay will be positioned within the established range, rather than at its minimum or maximum. This information is provided to applicants in accordance with states and local laws. **Application Deadline** : This will be posted for a minimum of 5 business days. **Company benefits:** Comprehensive medical, dental, vision, prescription drug coverage, company provided basic life, accidental death & dismemberment, short-term and long-term disability insurance, tuition reimbursement, student loan assistance, a generous 401(k) match, flexible time off, paid holidays, and paid leave programs as well as other company provided benefits. Come discover more about Otsuka and our benefit offerings; ********************************************* . **Disclaimer:** This job description is intended to describe the general nature and level of the work being performed by the people assigned to this position. It is not intended to include every job duty and responsibility specific to the position. Otsuka reserves the right to amend and change responsibilities to meet business and organizational needs as necessary. Otsuka is an equal opportunity employer. All qualified applicants are encouraged to apply and will be given consideration for employment without regard to race, color, sex, gender identity or gender expression, sexual orientation, age, disability, religion, national origin, veteran status, marital status, or any other legally protected characteristic. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation, if you are unable or limited in your ability to apply to this job opening as a result of your disability. You can request reasonable accommodations by contacting Accommodation Request (EEAccommodations@otsuka-us.com) . **Statement Regarding Job Recruiting Fraud Scams** At Otsuka we take security and protection of your personal information very seriously. Please be aware individuals may approach you and falsely present themselves as our employees or representatives. They may use this false pretense to try to gain access to your personal information or acquire money from you by offering fictitious employment opportunities purportedly on our behalf. Please understand, Otsuka will **never** ask for financial information of any kind or for payment of money during the job application process. We do not require any financial, credit card or bank account information and/or any payment of any kind to be considered for employment. We will also not offer you money to buy equipment, software, or for any other purpose during the job application process. If you are being asked to pay or offered money for equipment fees or some other application processing fee, even if claimed you will be reimbursed, this is not Otsuka. These claims are fraudulent and you are strongly advised to exercise caution when you receive such an offer of employment. Otsuka will also never ask you to download a third-party application in order to communicate about a legitimate job opportunity. Scammers may also send offers or claims from a fake email address or from Yahoo, Gmail, Hotmail, etc, and not from an official Otsuka email address. Please take extra caution while examining such an email address, as the scammers may misspell an official Otsuka email address and use a slightly modified version duplicating letters. To ensure that you are communicating about a legitimate job opportunity at Otsuka, please only deal directly with Otsuka through its official Otsuka Career website ******************************************************* . Otsuka will not be held liable or responsible for any claims, losses, damages or expenses resulting from job recruiting scams. If you suspect a position is fraudulent, please contact Otsuka's call center at: ************. If you believe you are the victim of fraud resulting from a job recruiting scam, please contact the FBI through the Internet Crime Complaint Center at: ******************* , or your local authorities. Otsuka America Pharmaceutical Inc., Otsuka Pharmaceutical Development & Commercialization, Inc., and Otsuka Precision Health, Inc. ("Otsuka") does not accept unsolicited assistance from search firms for employment opportunities. All CVs/resumes submitted by search firms to any Otsuka employee directly or through Otsuka's application portal without a valid written search agreement in place for the position will be considered Otsuka's sole property. No fee will be paid if a candidate is hired by Otsuka as a result of an agency referral where no pre-existing agreement is in place. Where agency agreements are in place, introductions are position specific. Please, no phone calls or emails.

**Your Future Evolves Here** Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. **What You'll Be Doing:** As a Field Medical Director, MSK Surgery you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients' lives, in a non-clinical environment. You can enjoy better work- life balance on a team that values collaboration and continuous learning while providing better health outcomes. Collaboration Opportunities: + Routinely interacts with leadership and management staff, other Physicians, and staff whenever a physician`s input is needed or required. What You Will Be Doing: + Serve as the Physician match reviewer in Hip/Knee/Shoulder Surgery cases, that do not initially meet the applicable medical necessity guidelines, as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert. + Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request and provides clinical rationale for standard and expedited appeals. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) guidelines. + Aids and acts as a resource to Initial Clinical Reviewers. + Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner. + May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support. + Participates in on-going training per inter-rater reliability process. Qualifications: + MD/DO/MBBS + Minimum of five (5) years' experience in the practice of Medicine, post residency and Active Clinical practice within the last 2 years is highly preferred + Current, unrestricted clinical license in medicine or required specialty + Obtaining and maintaining medical licenses in the state you reside, as well as, any license required per business needs + Active Board Certification in Orthopedic Surgery + Strong clinical, management, communication, and organizational skills + Energetic and curious with a passion for quality and value in health care + Computer Proficiency + Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare. + No history of a major disciplinary or legal action by a state medical board To ensure a secure hiring process we have implemented several identity verification steps, including submission of a government issued photo ID. We conduct identity verification during interviews, and final interviews may require onsite attendance. All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment. The use of artificial intelligence tools during interviews is prohibited and monitored. Misrepresentation will result in immediate disqualification from consideration. **Technical Requirements:** We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations. **Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.** **If you need reasonable accommodation to access the information provided on this website, please contact** ************************** **for further assistance.** The expected base salary/wage range for this position is $130-$150/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts. Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!

This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service. Depending on the nature of the case, telephonic peer to peer discussions may be required. The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management. They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the incumbent may be assigned special projects to help support and improve the care of our members **ESSENTIAL RESPONSIBILITIES** + Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with community standards of care. + Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise multidisciplinary team on cases that require physician expertise. + Participate in protocol and guidelines development to ensure consistency in the review process. + Actively manage projects and/or participate on project teams that require a physician subject matter expert. + Other duties as assigned. **EDUCATION** **Required** + Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) **Substitutions** + None **Preferred** + Master's Degree in Business Administration/Management or Public Health **EXPERIENCE** **Required** + 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice) **Preferred** + 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry **LICENSES AND CERTIFICATION** **Required** + Medical Doctor or Doctor of Osteopathic Medicine (DO) + Awarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards + Active medical state licensure required. Additional specific state licensure(s) may be required based on business need. **Preferred** + None **SKILLS** + Critical Thinking + Case Management + Customer Service + Oral & Written Communication Skills + Collaboration + Listening + Telephone Skills + General Computer Skills + Clinical Software + Managed Care **Language (Other than English)** None **Travel Required** 0% - 25% **PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS** Position Type Office-Based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required No Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Rarely Lifting: 25 to 50 pounds Rarely **_Disclaimer:_** _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job._ **_Compliance Requirement_** _: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies._ _As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy._ _Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._ **Pay Range Minimum:** $170,000.00 **Pay Range Maximum:** $352,500.00 _Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets._ Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at ***************************** California Consumer Privacy Act Employees, Contractors, and Applicants Notice Req ID: J272806

**Become a part of our caring community and help us put health first** Become a part of our caring community and help us put health first The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, level of care, and/or site of service should be authorized. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work. Willingness to work every other weekend with compensated days off during the work week The Medical Director's work includes reviewing of all submitted medical records, synthesizing complex hospital-based clinical scenarios, and providing expert decisioning on the requested services. They will have regular discussions with external providers by phone to gather additional clinical information and discuss determinations. Medical directors are expected to understand Humana processes with a focus on collaborative professional relationships. The ideal candidate will have a high degree of integrity, professionalism, resourcefulness, and enjoy working in a team-based environment. Medical Directors support Humana value throughout all activities. **Responsibilities** The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are concordant with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. After completion of structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members. The ideal candidate enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines. + Conduct comprehensive, timely, and compliant medical necessity reviews for inpatient services + Maintain accountability for productivity, quality, and compliance metrics + Communicate determinations clearly both verbally and in writing + Demonstrate adaptability and willingness to learn evolving workflows, tools, and utilization management practices + **Willingness to work every other weekend with compensated days off during the work week** **Use your skills to make an impact** **Use your skills to make an impact** **Required Qualifications** + MD or DO degree + 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age). + Current and ongoing Board Certification an approved ABMS Medical Specialty + A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required. + No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. + Excellent verbal and written communication skills. + Evidence of analytic and interpretation skills, with prior experience working in a team environment **Preferred Qualifications** + Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other Medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, or other healthcare providers. + Utilization management experience in a medical management review organization, such as Medicare Advantage, Managed Medicaid, or Commercial health insurance. + Experience with national guidelines such as MCG or InterQual + Experience in hospital-based clinical practice, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and hospital-based clinical specialists + The curiosity to learn and the flexibility to adapt to changes in order to enhance efficiency, productivity, and organizational goals. + Ability to thrive in a dynamic fast-paced, team-oriented environment. + Commitment to a culture of innovation, including being facile with using technology to improve workflows + Participate in educational activities by attending required conferences and also create content to lead/teach/present for individual subject matter contribution + Passionate about contributing to an organization's focus on consistency in outcomes, consumer experiences and a highly engaged team culture **Additional Information** The medical director reports to a Lead Medical Director. Participation in weekend work on a rotational basis to ensure cases are decisioned in a timely manner May participate on project teams or organizational committees. \#physiciancareers Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $223,800 - $313,100 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 02-28-2026 **About us** Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ***************************************************************************

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. **Position Purpose:** Supervisory Medical Director at Centene plays a critical role in delivering medical, people leadership and expertise to ensure the delivery of high-quality, cost-effective care to our members. This role further assists the Senior Medical Director or Chief Medical Officer in execution of strategic clinical initiatives. + Provide people leadership, coaching and mentorship for a team of front-line medical directors including but not limited to scheduling needed Utilization Management coverage, annual goal development, monthly 1:1s, mentorship/career development, and annual evaluations + Support Chief Medical Officer in the execution of strategic clinical initiatives + Participate in utilization review studies, evaluate adverse trends; and collaborate with CMO to develop solutions + Handle complex and high-profile utilization management cases, ensuring timely and appropriate decision-making + Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes + Conduct and participate in peer-to-peer reviews, collaborating with healthcare providers to discuss cases, answer questions, resolve disputes, and facilitate implementation of recommendations to providers that would improve utilization and health care quality + Oversee and actively participate in the appeals process, ensuring that appeals are handled efficiently, thoroughly, and in compliance with regulatory requirements + Provide clinical guidance to care managers and support the development of individualized care plans + As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues as well as appropriate state committees and other ad hoc committees + Collaborate closely with clinical teams, appeals team, and network providers to ensure understanding and adherence to utilization management policies + Performs other duties as assigned + Complies with all policies and standards **Education/Experience:** + Medical Doctor (MD) Graduate of an accredited medical school required + Master's Degree MBA, MPH, preferred + 5+ years Managed care/ clinical experience; experienced with commercial, Medicare and Medicaid lines of business required + 1+ years Supervisory/management experience preferred + Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services required + Certification in Internal or Family Medicine specialty preferred + Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs required Pay Range: $236,500.00 - $449,300.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

When you join the team at Unum, you become part of an organization committed to helping you thrive. Here, we work to provide the employee benefits and service solutions that enable employees at our client companies to thrive throughout life's moments. And this starts with ensuring that every one of our team members enjoys opportunities to succeed both professionally and personally. To enable this, we provide: + Award-winning culture + Inclusion and diversity as a priority + Performance Based Incentive Plans + Competitive benefits package that includes: Health, Vision, Dental, Short & Long-Term Disability + Generous PTO (including paid time to volunteer!) + Up to 9.5% 401(k) employer contribution + Mental health support + Career advancement opportunities + Student loan repayment options + Tuition reimbursement + Flexible work environments **_*All the benefits listed above are subject to the terms of their individual Plans_** **.** And that's just the beginning... With 10,000 employees helping more than 39 million people worldwide, every role at Unum is meaningful and impacts the lives of our customers. Whether you're directly supporting a growing family, or developing online tools to help navigate a difficult loss, customers are counting on the combined talents of our entire team. Help us help others, and join Team Unum today! **General Summary:** This position is responsible for providing expert medical analysis of claims files (or underwriting applications) across Unum US product lines. The incumbent provides high quality, timely, and efficient medical consultative services to the Benefits Center. The Medical Consultant adheres to current regulatory, claim process, and internal workflow standards as set forth in the Benefits Center Claims Manual, underwriting manual, and associated documentation. The incumbent adheres to accepted norms of medical practices and Code of Conduct guidelines. Physicians and psychologists conduct their reviews and analyses within appropriate ethical standards and maintain their professional licenses and Board certifications. This role is expected to provide excellent customer service and to interact on a regular basis with business partners, health care providers, and other specialized resources. **Principal Duties and Responsibilities** + Provide timely, clear medical direction and opinions to team partners, with reasoned forensic analysis to support the medical opinions + Partner/consult with fellow medical consultants when appropriate to ensure the completion of a whole person analysis + Apply medical knowledge to determine functional capacity through assessment of medical and other data related to impairment, regarding accuracy of diagnoses, treatment plans, duration guidelines, and prognosis + Provide relevant medical education and knowledge to others in terms appropriate and understandable to the intended audience + Perform telephone contacts with the insured's healthcare providers to gather medical information and to facilitate a better understanding of the claimant's functional abilities + Make timely and appropriate referrals for second opinion reviews when appropriate or required according to current guidelines and best practices + Demonstrate ability to manage and complete high volumes of assigned work, maintain consistently good turnaround times, and operate with a sense of urgency + Focus not only on individual workload, but on the team/group work volumes to ensure organizational success + Receive feedback and follow through with appropriate behaviors/actions + Perform other duties as assigned **Job Specifications** + Professional Degree (MD, DO, PhD, PsyD) + Active, unrestricted US medical license + Board certification required for physicians in their area of specialty + Minimum of five years of clinical experience in medical specialty + Strong team and collaborative skills. Ability to work in a fast paced, team based, corporate environment + Ability to mentor others and to give and receive constructive, behaviorally based feedback with peers and partners \#IN1 \#LI-RA1 Unum and Colonial Life are part of Unum Group, a Fortune 500 company and leading provider of employee benefits to companies worldwide. Headquartered in Chattanooga, TN, with international offices in Ireland, Poland and the UK, Unum also has significant operations in Portland, ME, and Baton Rouge, LA - plus over 35 US field offices. Colonial Life is headquartered in Columbia, SC, with over 40 field offices nationwide. Unum is an equal opportunity employer, considering all qualified applicants and employees for hiring, placement, and advancement, without regard to a person's race, color, religion, national origin, age, genetic information, military status, gender, sexual orientation, gender identity or expression, disability, or protected veteran status. The base salary range for applicants for this position is listed below. Unless actual salary is indicated above in the job description, actual pay will be based on skill, geographical location and experience. $133,500.00-$274,100.00 Additionally, Unum offers a portfolio of benefits and rewards that are competitive and comprehensive including healthcare benefits (health, vision, dental), insurance benefits (short & long-term disability), performance-based incentive plans, paid time off, and a 401(k) retirement plan with an employer match up to 5% and an additional 4.5% contribution whether you contribute to the plan or not. All benefits are subject to the terms and conditions of individual Plans. Company: Unum

**_What Finance Operations contributes to Cardinal Health_** Finance oversees the accounting, tax, financial plans and policies of the organization, establishes and maintains fiscal controls, prepares and interprets financial reports, oversees financial systems and safeguards the organization's assets. Finance Operations is responsible for core financial operation processes. This can include customer and vendor contract administration; customer and vendor pricing, rebates, billing vendor chargeback research and reconciliation; processing vendor invoices and employee expense reports for payment; fixed asset accounting for book and tax records; cash application; and journal entries. + Demonstrates knowledge of financial processes, accounting policies, systems, controls, and work streams + Demonstrates experience working in a transnational finance environment coupled with strong internal controls + Possesses understanding of service level goals and objectives when providing customer support + Works collaboratively to respond to non-standard requests + Possesses strong organizational skills and prioritizes getting the right things done **_Responsibilities_** + Manage a team of Cardinal Health and Genpact individuals who oversee the entirety of the GPO Admin Fees and Rebates set up and report creation functions, including P&L accruals, rebate setups within SAP Vistex and ad hoc reporting for key internal and external stakeholders. Responsible for the month end accounting close process. + Ensure GPO Admin Fees and Rebates are properly accounted for based on core accounting principles + Own first level review/approval responsibilities for non-standard rebate structures to ensure proper audit documentation is maintained and proper approvals are received + Oversee key rebate accuracy and timeliness CSLs and KPIs + Partner with cross-functional teams to research and resolve root cause issues impacting rebate accuracy or ability to set up Rebates and GPO Admin Fees timely; apply big picture knowledge to assess and interpret financial impact of process changes and resulting driver outcomes of GPO Admin Fee/Rebate set up changes + Foster a strong SOX internal control structure and seek opportunities for improvements, including build out of SOP processes and project development + Transform current payout and reporting process into Vistex implementation and go-forward build/upkeep + Develop plans for future systematic enhancements + Assist team with more complicated customer and transaction activities; oversee escalations to ensure closure in a timely manner + Partner with and be a thought-provoking leader to business partners across the organization to properly account for transactions, including but not limited to Sales, Legal, Finance, Pricing, Accounting and Contracting + Actively collaborate and support cross-functional team initiatives to improve customer experience, both internally and externally + Establish team and individual-oriented goals for growth and development **_Qualifications_** + Bachelor's Degree in Accounting, Finance or Business Management, preferred + CPA preferred + 8+ years of professional experience in related field, preferred, including Accounting, Finance, or Audit, preferred + Accounting and Finance acumen + Ability to lead a new team and influence others + Knowledge with SAP and legal contracts (revenue recognition standards is a plus) + Data mining experience (relevant application tool experience is a plus) + Strong written and verbal communication skills + Process improvement oriented + Strong SOX/internal control understanding **Anticipated salary range:** $105,100 - $135,090 **Bonus eligible:** Yes **Benefits:** Cardinal Health offers a wide variety of benefits and programs to support health and well-being. + Medical, dental and vision coverage + Paid time off plan + Health savings account (HSA) + 401k savings plan + Access to wages before pay day with my FlexPay + Flexible spending accounts (FSAs) + Short- and long-term disability coverage + Work-Life resources + Paid parental leave + Healthy lifestyle programs **Application window anticipated to close:** 1/16/2026 *if interested in opportunity, please submit application as soon as possible. The salary range listed is an estimate. Pay at Cardinal Health is determined by multiple factors including, but not limited to, a candidate's geographical location, relevant education, experience and skills and an evaluation of internal pay equity. _Candidates who are back-to-work, people with disabilities, without a college degree, and Veterans are encouraged to apply._ _Cardinal Health supports an inclusive workplace that values diversity of thought, experience and background. We celebrate the power of our differences to create better solutions for our customers by ensuring employees can be their authentic selves each day. Cardinal Health is an Equal_ _Opportunity/Affirmative_ _Action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, ancestry, age, physical or mental disability, sex, sexual orientation, gender identity/expression, pregnancy, veteran status, marital status, creed, status with regard to public assistance, genetic status or any other status protected by federal, state or local law._ _To read and review this privacy notice click_ here (***************************************************************************************************************************

**Become a part of our caring community and help us put health first** The Director Denials Management provides leadership for the audit, appeal and review process to preserve and recover revenue while maintaining the highest level of clinical and regulatory integrity and compliance. Manages the Denials Management data analytics, denial and appeal process. The Director, Home Health Grievances & Appeals assists members, via phone or face to face, further/support quality related goals. Investigates and resolves member and practitioner issues. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance. Provides input into functions strategy. **Responsibilities:** + Oversee the process for direction and support to clinical and operational leadership regarding Medicare and governmental audit trends, denials, and any CMS initiative and/or demonstration projects. + Collaborates with leadership team in the development of an education plan to improve processes to preserve and recover revenue. + Analyzes region-wide outcome indicators to measure achievement of quantitative and qualitative standards. Assists in the development, implementation and analysis of internal and external benchmarking programs to measure the region's effectiveness in improving performance + Maintains region-wide Performance Improvement program which includes Customer Satisfaction, complaints, infection monitoring, Incident Reporting, and quarterly branch PI activity + Provides feedback and recommendations for changes to policies and processes, procedures and systems to enhance measures taken to improve performance + Communicate with Corporate leadership, Regional and Divisional leaders as appropriate to resolve issues that may place patients or the company at risk + Oversee educational in-services based on analysis of PI data and activities Acts as a resource for the Operations Support team and communicates Performance Improvement results + Participate in special projects and performs other duties as assigned. **Use your skills to make an impact** **Required Qualifications** + Bachelor's degree in Nursing or related field + 10-15 years progressively responsible experience in home health or hospice industry that includes performance improvement and outcomes measurement + 5 years' experience in a supervisory or teaching role + Thorough knowledge of health care policy, industry and related clinical practice + Knowledge in the interpretation and application of regulations and performance improvement standards + Strong Project management principles and clinical policy development/implementation required + Expert knowledge of all Medicare regulations and appeals processes + Excellent analytical skills with ability to interpret and apply regulatory requirements + Excellent verbal/written communication and presentation skills + Advanced knowledge with Payer requirements, ADR requests, Denials, Appeals, RAC/ZPIC and CERT responses + Must be able to work well independently and in a team environment + Excellent communication and organization skills + Strong attention to detail + Healthcare industry experience preferred + Must read, write and speak fluent English + Must have good and regular attendance + Approximate percent of time required to travel: 30% + Performs other related duties as assigned **Preferred Qualifications** + Master's Degree preferred + Licenses/Certification: RN, PT or OT preferred + More than 3 years of grievance and appeals experience + Strong knowledge in Microsoft Access or experience with SQL Server databases + Previous experience processing medical claims + Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish **Additional Information** **SSN Alert Statement** Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from ******************** with instructions on how to add the information into your official application on Humana's secure website. **Interview Format** As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. **WAH Internet Statement** To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $126,300 - $173,700 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 01-30-2026 **About us** About CenterWell Home Health: CenterWell Home Health specializes in personalized, comprehensive home care for patients managing a chronic condition or recovering from injury, illness, surgery or hospitalization. Our care teams include nurses, physical therapists, occupational therapists, speech-language pathologists, home health aides, and medical social workers - all working together to help patients rehabilitate, recover and regain their independence so they can live healthier and happier lives. About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation's largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first - for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our full accessibility rights information and language options *************************************************************

Earn up to $100,000 in compensation** Peak Sport and Spine is looking for a full-time, self-motivated physical therapist who is dedicated to providing high quality patient centered care. We offer numerous opportunities for our employees to grow as we grow. We are a well-established, therapist owned, outpatient physical therapy clinic serving Camdenton, MO. When visiting our clinic, patients experience prompt scheduling, unparalleled customer service, and specialized treatment. Peak Sport and Spine has an orthopedic focus and we also treat a variety of other patients and conditions. Our company provides Clinic Directors an excellent opportunity for those clinicians who wish to grow and advance their clinical, managerial, and entrepreneurial skills. We set the bar high in our expectations, but we also give you the necessary tools, time, and training to be successful. We offer an environment focused on your professional and financial growth. Curious what it's like to work at Peak Sport and Spine? Email us at ***************** to set up a time to visit one of our facilities. Be sure to check us out on Instagram, Facebook, and LinkedIn @PeakSportSpine to get a glimpse of what it's like to be part of our team. Benefits: Individualized Mentorship Leadership Development Continuing Education Reimbursement and MedBridge Access Quarterly Bonus/Profit Share Opportunity 401k with company match up to 4% Health, Dental, and Vision 100% Paid Telehealth Benefits (enrolled employees and family) Health Savings Account Life Insurance Short and Long Term Disability Paid Time Off and Holidays Requirements Required Qualifications: Degree from an accredited physical therapy program Active Missouri Physical Therapy License Experience in outpatient orthopedics Strong communication and interpersonal skills Ability to thrive in a team environment. Salary Description Starting at $75,000 annually

Find your calling at Mercy! The Director - Behavioral Health is a strategic and functional leader that is responsible for the overall operational management of behavioral health programs within their scope. This includes responsibility for the business operations and patient care of mental health and behavioral health facilities and programs. This role is responsible for implementation and monitoring of program efficacy, fiscal stewardship of healthcare resources, quality evaluation and improvement, staff competency and performance, engaging effectively with key internal and external stakeholders, ensuring compliance with regulatory requirements and program growth and development. Position Details: Education : BSN Graduate of an approved College of Nursing. Master's degree in Nursing, Health Administration or related field, or plan for completion within a specific period of time. Licensure : Licensed as a Registered Nurse in the state of practice. Experience : Previous experience of 2-4 years of a Nurse Manager in a hospital of comparable size and/or accountability. Capable of working cooperatively with other executives, physicians and co-workers in order to accomplish goals. Able to communicate effectively in writing and orally and able to coordinate and integrate the complexities of patient care. Why Mercy? From day one, Mercy offers outstanding benefits - including medical, dental, and vision coverage, paid time off, tuition support, and matched retirement plans for team members working 32+ hours per pay period. Join a caring, collaborative team where your voice matters. At Mercy, you'll help shape the future of healthcare through innovation, technology, and compassion. As we grow, you'll grow with us. By applying, you consent to your information being transmitted by Get It to the Employer, as data controller, through the Employer's data processor SonicJobs. See Mercy Terms & Conditions at ****************************************** and Privacy Policy at ****************************************** and SonicJobs Privacy Policy at ******************************************* and Terms of Use at *********************************************

The Medical Director, Rare Disease is a critical role responsible for shaping the strategic processes and planning for assets in across phases of development within the Rare Disease portfolio. This position manages the unique challenge of establishing an emerging portfolio, incorporating newly acquired assets, which requires significant scientific and strategic agility and a strong ability to balance competing priorities. This position reports directly to the Rare Disease Medical Business Unit (BU) Lead. **** **Key Responsibilities Include:** **Medical Strategy & Narrative** + Provide key medical input into the initial development of the Target Reimbursable Product Profile as well as early development plans ensuring scientific consistency and alignment across functions (e.g., R&D, Clinical, Global Medical Affairs) + Provide high-quality scientific/clinical input and review of early asset plans, ensuring content aligns with the overarching Medical Narrative + Lead and nurture strategic partnerships with stakeholders by ensuring clear, consistent communication and aligning initiatives with partner priorities to strengthen collaboration and drive shared success in the rare disease space + Serve as a primary scientific resource, providing guidance on the disease state and mechanism of action for the Rare Disease portfolio helping to translate science into value for patients and stakeholders + Lead the Strategy and Tactical Planning Process, identifying critical data needs for the emerging portfolio **Evidence Generation Process** + Oversee the Medical Evidence Generation Process in partnership with GIE&I, translating strategic data gaps into clear research priorities and providing expert input into the design and feasibility of innovative clinical trials and data generation initiatives + Support the planning and execution of Medical Affairs evidence generation activities relevant to the Rare Disease portfolio **External Stakeholder Engagement** + Identify and engage a wide variety of stakeholders, including KOL experts and patient advocacy groups to support collection, curation and communication of clinical Medical and methodological insights to inform understanding of unmet medical needs, emerging standard of care and development opportunities + Develop Key Intelligence Topics & Questions (KITs/KIQs) for relevant assets, serving as the blueprint for insight collection from Key Opinion Leaders + Lead the strategic planning, content development, and successful facilitation of consulting activities including Advisory Boards, ensuring objectives align with data gap analyses and asset/portfolio strategy + Lead scientific exchange with key opinion leaders (KOLs) to gather insights and validate development hypotheses + Support the development of scientific publications, abstracts, and presentations related to the Rare Disease portfolio **Cross-functional Integration & Planning** + Collaborate within the Rare Disease Medical Business Unit with the Rare Disease Medical Communications and Field Medical Affairs sub-teams + Partner with and serve as a scientific and clinical resource for cross-functional colleagues including Clinical Development, Global Integrated Evidence & Innovation, Regulatory and Global Marketing and Market Access + Support indication prioritization and portfolio planning for early assets + Manage assigned Rare Disease medical program budgets in partnership with the Rare Disease Medical BU lead, ensuring accurate forecasting, responsible resource utilization, and compliance with internal policies and external regulations + Consider technology and AI to support workflow improvement **Qualifications** **Education and Experience:** + Advanced scientific degree is required (PharmD, MD, PhD, or equivalent) with extensive expertise in Rare Disease + Minimum of 5+ years of relevant experience in the pharmaceutical industry, with strong preference for experience in Clinical Development, Research, or Medical Affairs + Experience supporting BD evaluations for potential acquisitions + Experience contributing to the integration and strategic planning for newly acquired or in-licensed assets + Proven experience managing Evidence Generation processes and executing scientific Advisory Boards **Skills and Competencies:** + Strong leadership presence and ability to present to executive leadership team + Skilled in cultivating strong relationships with global medical partners through proactive communication and strategic prioritization + Motivated and solution-oriented with the ability to work collaboratively across the organization, particularly with R&D and Clinical teams + Strategic agility required to build and adapt scientific strategy for an emerging portfolio + Excellent communication and interpersonal skills, including experience presenting complex development strategies to large internal groups and engaging a limited number of highly specialized external experts + Full understanding of rules and regulations in pharma, with the ability to apply knowledge of guidelines and regulations to early-stage Medical Affairs activities + Ability to work in a fast-paced, dynamic environment, with a proactive and problem-solving mindset + Strong understanding of drug development processes, especially early-stage development + Openness to travel up to ~25% for 3 - 6 conferences in US and globally **Competencies** **Accountability for Results -** Stay focused on key strategic objectives, be accountable for high standards of performance, and take an active role in leading change. **Strategic Thinking & Problem Solving -** Make decisions considering the long-term impact to customers, patients, employees, and the business. **Patient & Customer Centricity -** Maintain an ongoing focus on the needs of our customers and/or key stakeholders. **Impactful Communication -** Communicate with logic, clarity, and respect. Influence at all levels to achieve the best results for Otsuka. **Respectful Collaboration -** Seek and value others' perspectives and strive for diverse partnerships to enhance work toward common goals. **Empowered Development -** Play an active role in professional development as a business imperative. Minimum $209,599.00 - Maximum $313,375.00, plus incentive opportunity: The range shown represents a typical pay range or starting pay for individuals who are hired in the role to perform in the United States. Other elements may be used to determine actual pay such as the candidate's job experience, specific skills, and comparison to internal incumbents currently in role. Typically, actual pay will be positioned within the established range, rather than at its minimum or maximum. This information is provided to applicants in accordance with states and local laws. **Application Deadline** : This will be posted for a minimum of 5 business days. **Company benefits:** Comprehensive medical, dental, vision, prescription drug coverage, company provided basic life, accidental death & dismemberment, short-term and long-term disability insurance, tuition reimbursement, student loan assistance, a generous 401(k) match, flexible time off, paid holidays, and paid leave programs as well as other company provided benefits. Come discover more about Otsuka and our benefit offerings; ********************************************* . **Disclaimer:** This job description is intended to describe the general nature and level of the work being performed by the people assigned to this position. It is not intended to include every job duty and responsibility specific to the position. Otsuka reserves the right to amend and change responsibilities to meet business and organizational needs as necessary. Otsuka is an equal opportunity employer. All qualified applicants are encouraged to apply and will be given consideration for employment without regard to race, color, sex, gender identity or gender expression, sexual orientation, age, disability, religion, national origin, veteran status, marital status, or any other legally protected characteristic. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation, if you are unable or limited in your ability to apply to this job opening as a result of your disability. You can request reasonable accommodations by contacting Accommodation Request (EEAccommodations@otsuka-us.com) . **Statement Regarding Job Recruiting Fraud Scams** At Otsuka we take security and protection of your personal information very seriously. Please be aware individuals may approach you and falsely present themselves as our employees or representatives. They may use this false pretense to try to gain access to your personal information or acquire money from you by offering fictitious employment opportunities purportedly on our behalf. Please understand, Otsuka will **never** ask for financial information of any kind or for payment of money during the job application process. We do not require any financial, credit card or bank account information and/or any payment of any kind to be considered for employment. We will also not offer you money to buy equipment, software, or for any other purpose during the job application process. If you are being asked to pay or offered money for equipment fees or some other application processing fee, even if claimed you will be reimbursed, this is not Otsuka. These claims are fraudulent and you are strongly advised to exercise caution when you receive such an offer of employment. Otsuka will also never ask you to download a third-party application in order to communicate about a legitimate job opportunity. Scammers may also send offers or claims from a fake email address or from Yahoo, Gmail, Hotmail, etc, and not from an official Otsuka email address. Please take extra caution while examining such an email address, as the scammers may misspell an official Otsuka email address and use a slightly modified version duplicating letters. To ensure that you are communicating about a legitimate job opportunity at Otsuka, please only deal directly with Otsuka through its official Otsuka Career website ******************************************************* . Otsuka will not be held liable or responsible for any claims, losses, damages or expenses resulting from job recruiting scams. If you suspect a position is fraudulent, please contact Otsuka's call center at: ************. If you believe you are the victim of fraud resulting from a job recruiting scam, please contact the FBI through the Internet Crime Complaint Center at: ******************* , or your local authorities. Otsuka America Pharmaceutical Inc., Otsuka Pharmaceutical Development & Commercialization, Inc., and Otsuka Precision Health, Inc. ("Otsuka") does not accept unsolicited assistance from search firms for employment opportunities. All CVs/resumes submitted by search firms to any Otsuka employee directly or through Otsuka's application portal without a valid written search agreement in place for the position will be considered Otsuka's sole property. No fee will be paid if a candidate is hired by Otsuka as a result of an agency referral where no pre-existing agreement is in place. Where agency agreements are in place, introductions are position specific. Please, no phone calls or emails.

This role supports the Medical Policy team by bringing medical director level expertise, experience and knowledge to the team. They support the full-cycle ownership of commercial and Medicare Advantage medical policies, both developed internally and by vendors. This includes the writing of clinical criteria based on research, engagement of clinical and non-clinical team members for operational guidelines. The incumbent must have an understanding of medical coding (ICD-10, CPT, HCPS) as medical coding based off policy criteria falls within their scope. In addition to developing new policies, the incumbent ensures all existing medical policies, in their scope, are in accordance with NCQA and/or CMS requirements. The incumbent may be required to address escalated inquiries brought forward by internal/external partners. Conducts peer reviews as part of the quality review process. In addition to policy ownership, the incumbent participates in various work-groups and sub-committees as a clinical lead/expert. Trains and orients new staff to the department and policy procedures, and mentors new team members. Serves as a liaison between other departments and vendors as required. **ESSENTIAL RESPONSIBILITIES** + Full-cycle ownership of commercial and Medicare Advantage medical policy creation process including writing clinical criteria and oversight/ownership of the clinical presentations to committees for internally developed and vendor owned policies.Engage other departments, team members, strategic partners, and vendors to assist with research. + Provide clinical guidance to non-clinical team.This may include those who own Medicare Advantage policy updates, and those who support the commercial policy team. + Address escalated policy inquiries that require clinical expertise.This may include updating/revising existing medical policies. + Partner with Utilization Management and other operational teams to identify opportunities within medical policy. + Discover and cultivate innovative opportunities that drive significant improvements in healthcare quality and efficiency. + Other duties as assigned or requested. **EXPERIENCE** **Required** + 5 years of Active medical practice + 3 years of medical policy experience **Preferred** + 1 year of medical coding experience **SKILLS** + Critical Thinking + Oral and Written Communication + Listening + Telephone Skills + General Computer Skills, including Excel + Clinical Software + Email Software (Outlook) and Teams + MS Word + Managed Care **EDUCATION** **Required** + Doctor of Medicine or Doctor of Osteopathic Medicine **Substitutions** + None **Preferred** + None **LICENSES or CERTIFICATIONS** **Required** + Medical Doctor OR Doctor of Osteopathic Medicine (DO), Board certified in an American Board of Medical Specialties or Bureau of Osteopathic, Specialists recognized specialty credentialed in a Highmark network + Active medical state licensure required. Additional specific state licensure(s) may be required based on business need. **Preferred** + None **Language (Other than English):** + None **Travel Required:** + Less than 25% **PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS** **Position Type** + Office-Based or Remote Position **Physical work site required** + Never **_Disclaimer:_** _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job._ **_Compliance Requirement_** _: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies._ _As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy._ _Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._ **Pay Range Minimum:** $170,000.00 **Pay Range Maximum:** $352,500.00 _Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets._ Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at ***************************** California Consumer Privacy Act Employees, Contractors, and Applicants Notice Req ID: J273814

**Your Future Evolves Here** Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. **What You'll Be Doing:** As a Field Medical Director, Oncology, you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical environment. You can enjoy better work- life balance on a team that values collaboration and continuous learning while providing better health outcomes. **Collaboration Opportunities:** · Routinely interacts with leadership and management staff, other Physicians, and staff whenever a physician`s input is needed or required. **What You Will Be Doing:** · Serve as the Physician match reviewer in Advanced Imaging cases, that do not initially meet the applicable medical necessity guidelines, as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert. · Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request and provides clinical rationale for standard and expedited appeals. · Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) guidelines. · Aids and acts as a resource to Initial Clinical Reviewers. · Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner. · May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support. · Participates in on-going training per inter-rater reliability process. **Qualifications:** · MD/DO/MBBS · Minimum of five (5) years' experience in the practice of Medicine, post residency and Active Clinical practice within the last 2 years is preferred · Current, unrestricted clinical license in medicine or required specialty · Obtaining and maintaining medical licenses in the state you reside, as well as, any license required per business needs · Active Board Certification in Adult Medical Oncology · Strong clinical, management, communication, and organizational skills · Energetic and curious with a passion for quality and value in health car · Computer Proficiency · Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare. · No history of disciplinary or legal action by a state medical board To ensure a secure hiring process we have implemented several identity verification steps, including submission of a government issued photo ID. We conduct identity verification during interviews, and final interviews may require onsite attendance. All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment. The use of artificial intelligence tools during interviews is prohibited and monitored. Misrepresentation will result in immediate disqualification from consideration. **Technical Requirements:** We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations. **Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.** **If you need reasonable accommodation to access the information provided on this website, please contact** ************************** **for further assistance.** The expected base salary/wage range for this position is $110-$125. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts. Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!

**Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, CMS and state policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare, Medicare Advantage, and Medicaid requirements and will understand how to operationalize this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management. May occasionally participate in discussions with external physicians by phone to gather additional clinical information or discuss determinations which may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, dispute, grievance, and appeals processes, and outpatient services and equipment, within their scope. The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value-based care, population health, or disease or care management. Medical Directors support Humana values throughout all activities. **Use your skills to make an impact** **Responsibilities** The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS and state Medicaid requirements, Humana policies, clinical standards, and (in some cases) contracts. The ideal candidate supports and collaborates with other team members, other departments, and Humana colleagues. After completion of mentored training, daily work is performed with minimal direction. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines. Supports the assigned work with respect to market-wide objectives and community relations as directed. **Required Qualifications** + MD or DO degree + 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age). + Current and ongoing Board Certification an approved ABMS Medical Specialty + A current and unrestricted license in at least one jurisdiction and willing to obtain additional license(s), if required. + No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. + Excellent verbal and written communication skills. + Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services such as inpatient rehabilitation. **Preferred Qualifications** + Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. + Experience with national guidelines such as MCG or InterQual + Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists + Advanced degree such as an MBA, MHA, MPH + Exposure to Public Health, Population Health, analytics, and use of business metrics. + Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health. + The curiosity to learn, the flexibility to adapt and the courage to innovate **Additional Information** Typically reports to a Lead Medical Director, depending on the line of business. The Medical Director conducts Utilization Management or clinical validation of the care received by members in an assigned line of business, member population, or condition type. May also engage in dispute, grievance, and appeals reviews. May participate on project teams or organizational committees. \#physiciancareers Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $223,800 - $313,100 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 02-28-2026 **About us** Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ***************************************************************************

Job DescriptionDescription: Earn up to $100,000 in compensation** Peak Sport and Spine is looking for a full-time, self-motivated physical therapist who is dedicated to providing high quality patient centered care. We offer numerous opportunities for our employees to grow as we grow. We are a well-established, therapist owned, outpatient physical therapy clinic serving Camdenton, MO. When visiting our clinic, patients experience prompt scheduling, unparalleled customer service, and specialized treatment. Peak Sport and Spine has an orthopedic focus and we also treat a variety of other patients and conditions. Our company provides Clinic Directors an excellent opportunity for those clinicians who wish to grow and advance their clinical, managerial, and entrepreneurial skills. We set the bar high in our expectations, but we also give you the necessary tools, time, and training to be successful. We offer an environment focused on your professional and financial growth. Curious what it's like to work at Peak Sport and Spine? Email us at ***************** to set up a time to visit one of our facilities. Be sure to check us out on Instagram, Facebook, and LinkedIn @PeakSportSpine to get a glimpse of what it's like to be part of our team. Benefits: Individualized Mentorship Leadership Development Continuing Education Reimbursement and MedBridge Access Quarterly Bonus/Profit Share Opportunity 401k with company match up to 4% Health, Dental, and Vision 100% Paid Telehealth Benefits (enrolled employees and family) Health Savings Account Life Insurance Short and Long Term Disability Paid Time Off and Holidays Requirements: Required Qualifications: Degree from an accredited physical therapy program Active Missouri Physical Therapy License Experience in outpatient orthopedics Strong communication and interpersonal skills Ability to thrive in a team environment.

The Medical Director, Rare Disease is a critical role responsible for shaping the strategic processes and planning for assets in across phases of development within the Rare Disease portfolio. This position manages the unique challenge of establishing an emerging portfolio, incorporating newly acquired assets, which requires significant scientific and strategic agility and a strong ability to balance competing priorities. This position reports directly to the Rare Disease Medical Business Unit (BU) Lead. **** **Key Responsibilities Include:** **Medical Strategy & Narrative** + Provide key medical input into the initial development of the Target Reimbursable Product Profile as well as early development plans ensuring scientific consistency and alignment across functions (e.g., R&D, Clinical, Global Medical Affairs) + Provide high-quality scientific/clinical input and review of early asset plans, ensuring content aligns with the overarching Medical Narrative + Lead and nurture strategic partnerships with stakeholders by ensuring clear, consistent communication and aligning initiatives with partner priorities to strengthen collaboration and drive shared success in the rare disease space + Serve as a primary scientific resource, providing guidance on the disease state and mechanism of action for the Rare Disease portfolio helping to translate science into value for patients and stakeholders + Lead the Strategy and Tactical Planning Process, identifying critical data needs for the emerging portfolio **Evidence Generation Process** + Oversee the Medical Evidence Generation Process in partnership with GIE&I, translating strategic data gaps into clear research priorities and providing expert input into the design and feasibility of innovative clinical trials and data generation initiatives + Support the planning and execution of Medical Affairs evidence generation activities relevant to the Rare Disease portfolio **External Stakeholder Engagement** + Identify and engage a wide variety of stakeholders, including KOL experts and patient advocacy groups to support collection, curation and communication of clinical Medical and methodological insights to inform understanding of unmet medical needs, emerging standard of care and development opportunities + Develop Key Intelligence Topics & Questions (KITs/KIQs) for relevant assets, serving as the blueprint for insight collection from Key Opinion Leaders + Lead the strategic planning, content development, and successful facilitation of consulting activities including Advisory Boards, ensuring objectives align with data gap analyses and asset/portfolio strategy + Lead scientific exchange with key opinion leaders (KOLs) to gather insights and validate development hypotheses + Support the development of scientific publications, abstracts, and presentations related to the Rare Disease portfolio **Cross-functional Integration & Planning** + Collaborate within the Rare Disease Medical Business Unit with the Rare Disease Medical Communications and Field Medical Affairs sub-teams + Partner with and serve as a scientific and clinical resource for cross-functional colleagues including Clinical Development, Global Integrated Evidence & Innovation, Regulatory and Global Marketing and Market Access + Support indication prioritization and portfolio planning for early assets + Manage assigned Rare Disease medical program budgets in partnership with the Rare Disease Medical BU lead, ensuring accurate forecasting, responsible resource utilization, and compliance with internal policies and external regulations + Consider technology and AI to support workflow improvement **Qualifications** **Education and Experience:** + Advanced scientific degree is required (PharmD, MD, PhD, or equivalent) with extensive expertise in Rare Disease + Minimum of 5+ years of relevant experience in the pharmaceutical industry, with strong preference for experience in Clinical Development, Research, or Medical Affairs + Experience supporting BD evaluations for potential acquisitions + Experience contributing to the integration and strategic planning for newly acquired or in-licensed assets + Proven experience managing Evidence Generation processes and executing scientific Advisory Boards **Skills and Competencies:** + Strong leadership presence and ability to present to executive leadership team + Skilled in cultivating strong relationships with global medical partners through proactive communication and strategic prioritization + Motivated and solution-oriented with the ability to work collaboratively across the organization, particularly with R&D and Clinical teams + Strategic agility required to build and adapt scientific strategy for an emerging portfolio + Excellent communication and interpersonal skills, including experience presenting complex development strategies to large internal groups and engaging a limited number of highly specialized external experts + Full understanding of rules and regulations in pharma, with the ability to apply knowledge of guidelines and regulations to early-stage Medical Affairs activities + Ability to work in a fast-paced, dynamic environment, with a proactive and problem-solving mindset + Strong understanding of drug development processes, especially early-stage development + Openness to travel up to ~25% for 3 - 6 conferences in US and globally **Competencies** **Accountability for Results -** Stay focused on key strategic objectives, be accountable for high standards of performance, and take an active role in leading change. **Strategic Thinking & Problem Solving -** Make decisions considering the long-term impact to customers, patients, employees, and the business. **Patient & Customer Centricity -** Maintain an ongoing focus on the needs of our customers and/or key stakeholders. **Impactful Communication -** Communicate with logic, clarity, and respect. Influence at all levels to achieve the best results for Otsuka. **Respectful Collaboration -** Seek and value others' perspectives and strive for diverse partnerships to enhance work toward common goals. **Empowered Development -** Play an active role in professional development as a business imperative. Minimum $209,599.00 - Maximum $313,375.00, plus incentive opportunity: The range shown represents a typical pay range or starting pay for individuals who are hired in the role to perform in the United States. Other elements may be used to determine actual pay such as the candidate's job experience, specific skills, and comparison to internal incumbents currently in role. Typically, actual pay will be positioned within the established range, rather than at its minimum or maximum. This information is provided to applicants in accordance with states and local laws. **Application Deadline** : This will be posted for a minimum of 5 business days. **Company benefits:** Comprehensive medical, dental, vision, prescription drug coverage, company provided basic life, accidental death & dismemberment, short-term and long-term disability insurance, tuition reimbursement, student loan assistance, a generous 401(k) match, flexible time off, paid holidays, and paid leave programs as well as other company provided benefits. Come discover more about Otsuka and our benefit offerings; ********************************************* . **Disclaimer:** This job description is intended to describe the general nature and level of the work being performed by the people assigned to this position. It is not intended to include every job duty and responsibility specific to the position. Otsuka reserves the right to amend and change responsibilities to meet business and organizational needs as necessary. Otsuka is an equal opportunity employer. All qualified applicants are encouraged to apply and will be given consideration for employment without regard to race, color, sex, gender identity or gender expression, sexual orientation, age, disability, religion, national origin, veteran status, marital status, or any other legally protected characteristic. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation, if you are unable or limited in your ability to apply to this job opening as a result of your disability. You can request reasonable accommodations by contacting Accommodation Request (EEAccommodations@otsuka-us.com) . **Statement Regarding Job Recruiting Fraud Scams** At Otsuka we take security and protection of your personal information very seriously. Please be aware individuals may approach you and falsely present themselves as our employees or representatives. They may use this false pretense to try to gain access to your personal information or acquire money from you by offering fictitious employment opportunities purportedly on our behalf. Please understand, Otsuka will **never** ask for financial information of any kind or for payment of money during the job application process. We do not require any financial, credit card or bank account information and/or any payment of any kind to be considered for employment. We will also not offer you money to buy equipment, software, or for any other purpose during the job application process. If you are being asked to pay or offered money for equipment fees or some other application processing fee, even if claimed you will be reimbursed, this is not Otsuka. These claims are fraudulent and you are strongly advised to exercise caution when you receive such an offer of employment. Otsuka will also never ask you to download a third-party application in order to communicate about a legitimate job opportunity. Scammers may also send offers or claims from a fake email address or from Yahoo, Gmail, Hotmail, etc, and not from an official Otsuka email address. Please take extra caution while examining such an email address, as the scammers may misspell an official Otsuka email address and use a slightly modified version duplicating letters. To ensure that you are communicating about a legitimate job opportunity at Otsuka, please only deal directly with Otsuka through its official Otsuka Career website ******************************************************* . Otsuka will not be held liable or responsible for any claims, losses, damages or expenses resulting from job recruiting scams. If you suspect a position is fraudulent, please contact Otsuka's call center at: ************. If you believe you are the victim of fraud resulting from a job recruiting scam, please contact the FBI through the Internet Crime Complaint Center at: ******************* , or your local authorities. Otsuka America Pharmaceutical Inc., Otsuka Pharmaceutical Development & Commercialization, Inc., and Otsuka Precision Health, Inc. ("Otsuka") does not accept unsolicited assistance from search firms for employment opportunities. All CVs/resumes submitted by search firms to any Otsuka employee directly or through Otsuka's application portal without a valid written search agreement in place for the position will be considered Otsuka's sole property. No fee will be paid if a candidate is hired by Otsuka as a result of an agency referral where no pre-existing agreement is in place. Where agency agreements are in place, introductions are position specific. Please, no phone calls or emails.

This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service. Depending on the nature of the case, telephonic peer to peer discussions may be required. The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management. They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the incumbent may be assigned special projects to help support and improve the care of our members **ESSENTIAL RESPONSIBILITIES** + Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with community standards of care. + Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise multidisciplinary team on cases that require physician expertise. + Participate in protocol and guidelines development to ensure consistency in the review process. + Actively manage projects and/or participate on project teams that require a physician subject matter expert. + Other duties as assigned. **EDUCATION** **Required** + Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) **Substitutions** + None **Preferred** + Master's Degree in Business Administration/Management or Public Health **EXPERIENCE** **Required** + 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice) **Preferred** + 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry **LICENSES AND CERTIFICATION** **Required** + Medical Doctor or Doctor of Osteopathic Medicine (DO) + Awarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards + Active medical state licensure required. Additional specific state licensure(s) may be required based on business need. **Preferred** + None **SKILLS** + Critical Thinking + Case Management + Customer Service + Oral & Written Communication Skills + Collaboration + Listening + Telephone Skills + General Computer Skills + Clinical Software + Managed Care **Language (Other than English)** None **Travel Required** 0% - 25% **PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS** Position Type Office-Based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required No Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Rarely Lifting: 25 to 50 pounds Rarely **_Disclaimer:_** _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job._ **_Compliance Requirement_** _: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies._ _As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy._ _Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._ **Pay Range Minimum:** $170,000.00 **Pay Range Maximum:** $352,500.00 _Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets._ Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at ***************************** California Consumer Privacy Act Employees, Contractors, and Applicants Notice Req ID: J270842

**Your Future Evolves Here** Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. **What You'll Be Doing:** As a Physician Clinical Reviewer, Interventional Pain Management, you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients' lives, in a non-clinical environment. You can enjoy better work- life balance on a team that values collaboration and continuous learning while providing better health outcomes. **Collaboration Opportunities:** + Routinely interacts with leadership and management staff, other Physicians, and staff whenever a physician`s input is needed or required. Aids and acts as a resource to Initial Clinical Reviewers. **What You Will Be Doing:** + Serve as the Physician Clinical Reviewer for Interventional Pain Management, reviewing cases that do not initially meet the applicable medical necessity guidelines, as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert. + Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) guidelines. + Provides clinical rationale for standard and expedited appeals. + Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner. + Participates in on-going training per inter-rater reliability process. + On a requested basis, may function as Medical Director for selecting health plans or regions, assuming overall accountability for utilization management while working in conjunction with the Senior Medical Director. May assist the Senior Medical Director in research activities/questions. **Qualifications - Required and Preferred:** + MD/DO/MBBS- **Required** + Minimum of five (5) years' experience in the practice of Pain Medicine, post-residency- **Preferred** + Current, unrestricted clinical license in medicine or required specialty- **Required** + Obtaining and maintaining medical licenses in the state you reside and any required per business needs- **Required** + Active Board Certification in Pain Management or another Active Board Certification and clinical experience in Interventional Pain Management- **Required** + Strong clinical, management, communication, and organizational skills- **Required** + Energetic and curious with a passion for quality and value in health care- **Required** + Computer Proficiency- **Required** To ensure a secure hiring process we have implemented several identity verification steps, including submission of a government issued photo ID. We conduct identity verification during interviews, and final interviews may require onsite attendance. All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment. The use of artificial intelligence tools during interviews is prohibited and monitored. Misrepresentation will result in immediate disqualification from consideration. **Technical Requirements:** We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations. **Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.** **If you need reasonable accommodation to access the information provided on this website, please contact** ************************** **for further assistance.** The expected base salary/wage range for this position is $100-$110/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts. Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!