Medical Director

Overview

Responsibilities

NICU Clinical Review & Medical Necessity Determinations

• Review and evaluate NICU admissions, continued stays, level-of-care requests, transfers, and discharge-related services.
• Assess maternal, delivery, newborn, and NICU clinical documentation for medically complex neonates and critically ill newborns.
• Apply evidence-based clinical guidelines, coverage criteria, and Medicaid requirements when making determinations.
• Document clear and clinically supported medical necessity rationales.
• Evaluate gestational age, postmenstrual age, respiratory support, nutrition support, acuity, treatment needs, and discharge readiness.
• Support physician-level review of DRG validation and NICU level-of-care determinations.
• Prioritize reviews to meet regulatory, contractual, and operational turnaround requirements.
• Escalate complex or high-risk cases according to established policies.

Clinical Operations & Medicaid Support

• Maintain expertise in federal Medicaid regulations, state-specific requirements, and neonatal clinical policies.
• Support consistent application of neonatal utilization management standards across assigned states.
• Participate in neonatal quality improvement, care management, discharge planning, and clinical initiatives.
• Provide clinical expertise and guidance to internal teams regarding neonatal services.

Physician Collaboration & Peer Reviews

• Conduct peer-to-peer discussions with:
  • Neonatologists
  • Pediatric specialists
  • Hospital-based physicians
  • Treating providers
• Gather additional clinical information and discuss review outcomes.
• Manage complex clinical conversations professionally and effectively.
• Collaborate with providers, facilities, care management teams, and community stakeholders to support neonatal outcomes and care transitions.

Team & Coverage Responsibilities

• Provide cross-coverage support during planned absences, holidays, weekends, and peak workload periods.
• Collaborate with medical directors, neonatal clinical teams, and operational partners to ensure consistency in review practices.
• Promote ethical decision-making, regulatory compliance, and patient-centered care.

Required Qualifications

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• Board Certification in Neonatal-Perinatal Medicine recognized by the American Board of Pediatrics.
• Active, unrestricted medical license in Oklahoma and/or South Carolina.
• Ability to obtain and maintain additional state licenses as required.
• Minimum 5 years of post-training clinical practice experience in Neonatal-Perinatal Medicine.
• Recent experience providing direct patient care within a NICU environment.
• Experience conducting NICU utilization management reviews in:
  • Health plans
  • Independent review organizations
  • Hospital environments
  • Comparable payer or clinical settings
• Ability to meet credentialing requirements.
• No current federal or state sanctions.

Preferred Qualifications

• Experience working with Medicaid populations and neonatal services.
• Experience supporting:
  • NICU case management
  • Concurrent review
  • Prior authorization
  • Appeals
  • Peer-to-peer review
  • Utilization management operations
• Familiarity with healthcare quality accreditation standards.
• Experience with utilization management platforms such as:
  • MHK
  • CGX
  • Comparable systems
• Participation in or eligibility for the Interstate Medical Licensure Compact.

Key Skills

• Neonatal Intensive Care (NICU)
• Neonatal-Perinatal Medicine
• Utilization Management
• Medical Necessity Reviews
• Medicaid Clinical Operations
• Peer-to-Peer Reviews
• Level of Care Determinations
• DRG Validation
• Clinical Documentation Review
• Appeals & Prior Authorization
• Quality Improvement
• Regulatory Compliance
• Provider Collaboration