[Remote] Medical Director UM (Internal medicine)

Note: The job is a remote job and is open to candidates in USA. Pyramid Consulting, Inc is a leading player in the Healthcare Industry, and they are seeking a Medical Director UM (Internal medicine) for a contract opportunity. The role involves providing medical leadership in utilization management, overseeing quality improvement activities, and collaborating with clinical teams to optimize patient outcomes. Responsibilities • Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. • Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making. • Supports effective implementation of performance improvement initiatives for capitated providers. • Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. • Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. • Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. • Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. • Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. • Participates in provider network development and new market expansion as appropriate. • Assists in the development and implementation of physician education with respect to clinical issues and policies. • Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. • Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. • Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. • Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. • Develops alliances with the provider community through the development and implementation of the medical management programs. • As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. • Represents the business unit at appropriate state committees and other ad hoc committees. • May be required to work weekends and holidays in support of business operations, as needed. Skills • Utilization Management skills • MD or Doctor of Osteopathy • Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department Benefits • Health insurance (medical, dental, vision) • 401(k) plan • Paid sick leave (depending on work location) Company Overview • Pyramid Consulting, a global leader in workforce and technology solutions, empowers individuals and organizations to transform and thrive in the most challenging and competitive markets. It was founded in 1996, and is headquartered in Alpharetta, Georgia, USA, with a workforce of 5001-10000 employees. Its website is https://pyramidci.com/. Company H1B Sponsorship • Pyramid Consulting, Inc has a track record of offering H1B sponsorships, with 48 in 2025, 112 in 2024, 95 in 2023, 62 in 2022, 50 in 2021, 117 in 2020. Please note that this does not guarantee sponsorship for this specific role. Apply tot his job Apply To this Job