Job Description

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing whole-person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 6,000 health care providers, including primary and specialty care physicians, hospitals and ancillary providers. We have operated in the Arizona market for more than 12 years, based in Chandler, Arizona, and are an affiliate of Heritage Provider Network. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.

The Medical Director is a physician with strong clinical, administrative, and management experience. General duties include providing clinical expertise, medical interpretation, and decisions about the appropriateness of services; collaborating with Physician Advisors/Consultants; providing oversight of their review process; working collaboratively with Compliance and Quality on system initiatives; and coordinating with physician leaders in counseling medical staff in a manner consistent with the medical staff bylaws. The Medical Director will work closely with the supervisory and support staff necessary to carry out the administrative functions. At this time, the Medical Director has no direct reports.

This position plays a key role in utilization management, including prior authorizations and concurrent review. While experience in these areas is preferred, it is not required. Candidates should bring strong clinical judgment, a willingness to engage in managed care processes, and the ability to apply evidence-based decision-making to support high-quality, cost-effective care.

POSITION DUTIES & RESPONSIBILITES

• Conduct clinical review of cases for Prior Authorizations - Evaluate pre-service requests using MCG guidelines to determine medical necessity and alignment with health plan criteria.
• Conduct clinical review cases for Concurrent Reviews - Assess inpatient and ongoing treatment plans in real time, applying MCG criteria to support safe discharge planning and appropriate length of stay.
• Retrospective Reviews - Review services rendered post-care to ensure clinical appropriateness and documentation accuracy per MCG and regulatory standards.
• Apply clinical practice guidelines and conduct medical necessity determinations - Utilize MCG care guidelines and evidence-based medicine to review service requests. Make determinations that balance quality care, cost-effectiveness, and compliance with CMS and plan-specific policies.
• Collaborate with case management and care coordination teams - Partner with RNs, social workers, and care coordinators to support integrated care planning, identify barriers to discharge or treatment, and ensure coordinated transitions across settings.
• Participate in disease and chronic condition management initiatives - Contribute clinical insight to population health efforts and care pathways, particularly in managing high-risk chronic conditions. Collaborate in developing targeted interventions to reduce avoidable utilization.
• Conduct drug utilization reviews and evaluate new medical technologies - Review pharmaceutical requests and utilization trends for alignment with clinical evidence and formulary guidelines. Assess the clinical benefit of emerging technologies or procedures and support policy development as needed.
• Support transplant case oversight - Review transplant-related medical records and authorizations to ensure clinical appropriateness, timeliness, and compliance with payer protocols and transplant center requirements.
• Analyze data for clinical and operational improvement - Use utilization trends, denial rates, and outcome metrics to identify opportunities for process improvement. Provide actionable recommendations that support efficiency, regulatory compliance, and member outcomes.
• Ensure timely review and documentation aligned with regulatory requirements - Complete medical reviews within established turnaround times. Ensure all determinations are thoroughly documented in accordance with CMS, URAC, and NCQA standards, as well as internal SOPs.
• Participate in special projects and quality improvement initiatives as assigned - Provide clinical leadership in cross-functional teams for initiatives such as accreditation readiness, provider education, documentation improvement, or corrective action planning.
• Other duties as assigned.

EDUCATION, TRAINING AND EXPERIENCE

• Current Arizona license to practice medicine without restrictions.
• Medical Doctorate or Doctor of Osteopathy degree required with appropriate Board Certification or qualification and level of expertise typically gained through 5 years’ experience in clinical practice.
• 3 to 5 years of medical administrative experience, preferably with emphasis on managed care members and Medicare rules and regulations.
• Experience in developing utilization protocols and supporting and motivating the clerical and nursing staff.
• Confidence in medical decision-making and strong peer communication skills.
• Strong/creative UM experience and realistic approach to case management.
• Ability to research and integrate payor requirements into AZPC processes.
• Ability to interact with all levels of management, physicians, staff, health plan representatives, and outside agencies/vendors.
• Possess excellent communication, organizational, and influencing skills.
• Knowledge of computers and experience using MS Office Programs (i.e., Word, Excel, Outlook, and PowerPoint).

*This role requires 60 days FT in office presence. Hybrid options will be available following the 60-day period.*

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