Medical Director, Utilization Review

About Curative:

Curative is creating the future of health insurance with its first-of-its-kind employer-based plan. Leveraging experience from leading the national COVID-19 testing effort, Curative is now redefining health insurance through affordability, engagement, and simplicity. Their mission is to transform health insurance by eliminating financial barriers to care and guiding members at every step of their health journey, offering a competitive monthly premium with zero additional costs* for in-network care. Curative envisions a future where nothing stands between members and the care they need, focusing on a sustainable healthcare plan that makes it easy to actually achieve better health. We are a fast-paced, innovative startup looking for passionate individuals ready to roll up their sleeves and contribute to a healthier future.

Job Summary:

Curative is seeking an enthusiastic and highly skilled Medical Director to join our growing team. This pivotal role will be responsible for overseeing and performing utilization reviews, prior authorizations, and making crucial medical necessity determinations. The Medical Director will serve as a key clinical expert, ensuring appropriate resource utilization, promoting evidence-based care, and fostering positive relationships with practitioners through effective peer-to-peer discussions. This is a remote position requiring a "roll up your sleeves" attitude and a genuine excitement for the dynamic and collaborative environment of a startup.

Key Responsibilities:

Perform comprehensive medical necessity reviews (prospective, concurrent, and retrospective) for a wide range of healthcare services, applying clinical expertise, established medical policies, and evidence-based guidelines.

Conduct thorough prior authorization reviews, ensuring alignment with clinical criteria, regulatory requirements, and contractual agreements.

Lead and conduct effective peer-to-peer discussions with requesting practitioners, providing clear clinical rationales for determinations, facilitating open dialogue, and seeking alternative solutions when appropriate.

Issue medical necessity denials when warranted, providing comprehensive and well-documented rationales in compliance with all relevant regulations and appeal processes.

Collaborate closely with internal teams, including Nurse Practitioners, Care Coordinators, and Operations, to optimize utilization management processes and improve member outcomes.

Contribute to the development, review, and revision of medical policies, clinical guidelines, and utilization management protocols.

Participate in quality improvement initiatives, audits, and committee meetings as required.

Maintain meticulous documentation of all review activities, decisions, and peer-to-peer interactions.

Stay abreast of current medical literature, healthcare trends, regulatory changes, and industry best practices in utilization management.

Champion a member-centric approach while balancing clinical efficacy and cost-effectiveness.

Embrace the fast-paced, evolving nature of a startup environment, demonstrating adaptability and a proactive approach to problem-solving.

Qualifications:

Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school.

Board Certification in a medical specialty.

Active and unrestricted Medical License in at least one US state, with the ability to obtain additional state licenses as needed (Curative will support additional licensure processes).

Minimum of 5 years of clinical practice experience.

Minimum of 2-3 years of experience in utilization management, medical review, or prior authorizations within an insurance or managed care organization.

Demonstrated success in conducting peer-to-peer discussions with external practitioners, with excellent communication and interpersonal skills.

Profound understanding of medical necessity criteria, evidence-based medicine, and healthcare utilization management principles.

Strong analytical and critical thinking skills, with the ability to synthesize complex clinical information and make sound medical decisions.

Exceptional written and verbal communication skills, capable of explaining complex medical decisions clearly and empathetically.

Proficiency with electronic health records (EHR) systems and utilization management software.

Self-motivated, highly organized, and able to manage a high volume of cases effectively in a remote work environment.

A "roll up your sleeves" attitude and a genuine excitement for contributing to a rapidly growing, innovative startup.

No travel required for this position.

Benefits:

Competitive salary with a 20% annual bonus potential.

Unlimited Paid Time Off (PTO) – We believe in work-life balance and trust our team to manage their time effectively.

Comprehensive health, dental, and vision insurance.

Opportunity to be a key leader in transforming the health insurance industry.

A dynamic, collaborative, and innovative startup culture.

Professional development opportunities.

Employment Details:

This position is subject to a 120-day trial employment period.

Curative is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

*Every Curative member qualifies for the $0 deductible, $0 copay for in-network care, and preferred prescriptions by completing a Baseline Visit within 120 days of the plan's effective date.