The Medical Director provides cross-market clinical leadership and oversight, ensuring excellence in care delivery across Nest Health's growing footprint. This role blends system-level leadership with hands-on clinical engagement through ride alongs, chart reviews, and periodic patient care coverage. The Medical Director also serves as a clinical ambassador in external conversations.
The Prior Authorization Specialist will be a key member of the product team, supporting SmarterDx’s newest product launch to help health systems capture the full value of care delivered. You’ll guide how we design, test, and refine new product capabilities using your deep hands-on knowledge from large health systems. This is a unique opportunity to apply your prior authorization expertise in a cutting-edge health technology environment.
As an Investigative Clinician, you will blend clinical expertise with investigative acumen to detect, prevent, and resolve fraudulent, exaggerated, or non-medically necessary claims. You'll collaborate with adjusters, legal teams, and investigators to analyze medical documentation and uncover inconsistencies or red flags. Responsibilities include reviewing medical records, identifying patterns of fraud, providing clinical expertise, interviewing claimants, and preparing clinical summary reports.
As Senior Medical Director for Utilization Management (UM), you will be an effective change leader and help develop and guide the strategic direction for Utilization Management initiatives. It is essential to be a self-directed and results-oriented physician who leads by example to serve as Wellmark's subject matter expert on effective and efficient processes to reduce overuse and improve quality for our members. Internal + external relationship and trust building is essential for success.