Remote Medical doctor Jobs · Managed Care

• Provide senior clinical leadership across behavioral health programs and utilization management.
• Serve as primary clinical resource for complex case reviews, utilization decisions, and provider consultations.
• Drive quality improvement initiatives and ensure compliance with healthcare regulations and accreditation standards.

This partner company provides behavioral health programs and quality improvement initiatives, focusing on mental health and substance use disorder services. The company culture emphasizes mission-driven whole-person health and collaborative work with health plans and providers.

• Conduct coverage reviews and render determinations based on member benefits and medical policies.
• Document clinical findings and actions in accordance with regulatory and accreditation requirements.
• Engage in peer-to-peer discussions with providers and collaborate on benefit determinations.

Capital Blue Cross is a health insurance company that provides coverage and services. They are consistently voted as one of the Best Places to Work in Pennsylvania, reflecting a positive culture.

• Provide medical review and clinical determinations based on evidence-based criteria for therapy programs.
• Support clinical content team in reviewing guidelines and literature, and conduct peer-to-peer discussions with providers.
• Demonstrate professionalism and accountability in a fast-paced, team-oriented environment.

Cohere Health provides a clinical intelligence platform and agentic AI-powered solutions that connect health plans and providers, optimizing care speed, cost, and quality. The company is rapidly scaling, backed by leading investors, and has been named to the Inc. 5000 list and a Top 5 LinkedIn Startup for 2023 & 2024.