Senior Medical Director Health Plan Analytics & Policy Strategy

Job title: Senior Medical Director Health Plan Analytics & Policy Strategy role

Location: Remote

Department: Medical Management / Payment Integrity

Reports to: Chief Clinical Officer or SVP of Medical Affairs

Experience Level: 10+ years in a senior leadership role within health plan or payer environments

Position Overview:

We are seeking a strategic, data-driven Senior Medical Director with deep expertise in health plan operations, medical policy development, and cost management analytics. This role will be pivotal in identifying medical trend drivers and shaping interventions across utilization management, reimbursement strategy, claims integrity, and coverage policy benchmarking.

Key Responsibilities:

1. Trend Mitigation & Acuity Management

• Analyze claims data to identify shifts in acuity (e.g., increased sepsis coding intensity)
• Lead post-service review protocols to identify inappropriate DRG upcoding and clinical documentation anomalies
• Update medical policies to reflect evolving acuity trends
• Collaborate with UM teams to enhance concurrent review criteria for early identification of high-cost, low-value clinical practices

1. Reimbursement Strategy & Emerging Service Oversight

• Investigate and triage emerging billing patterns (e.g., novel imaging dyes, educational material charges)
• Partner with reimbursement policy leads to refine covered services and define appropriate billing conditions
• Develop clinical criteria to assess necessity vs. administrative inflation

1. Coverage Policy Benchmarking & Competitive Analysis

• Establish systematic benchmarking of medical and reimbursement policies across national and regional competitors
• Advise on the strategic implications of coverage decisions, especially in drug utilization and procedural coding (e.g., E&M during office-based procedures)
• Recommend updates to internal policies to ensure market competitiveness and fiscal stewardship

Desired Qualifications

• M.D., D.O., or equivalent clinical degree; Board Certification preferred
• 10+ years in clinical or executive medical roles within health plans, payers, or large risk-bearing organizations
• Proven experience developing and implementing medical/reimbursement policy and cost containment interventions
• Deep knowledge of DRG systems, utilization review standards, and claims data analytics
• Demonstrated ability to navigate complex stakeholder environments and regulatory frameworks

Key Interfaces

• Payment Integrity, UM/CM teams, Policy Analysts
• Compliance & Legal, Actuarial, Claims Operations
• External consultants, benchmarking collaborators.