Medical Director, Clinical Policy

Job Summary

The Medical Director, Clinical Policy provides clinical leadership and strategic oversight for the development, implementation, governance, and evaluation of clinical policies that guide the organization’s medical and utilization management practices. This position ensures clinical policies and utilization management frameworks are evidence-based, operationally sound, compliant with regulatory and accreditation requirements, and aligned with organizational goals related to quality, safety, affordability, and member experience.

The Medical Director oversees policy architecture, authorization strategy, and utilization oversight across all lines of business, ensuring clinical intent is accurately translated into authorization requirements, coding structures, and system configuration through partnership with internal teams. This position works collaboratively across internal departments to support consistent, high-quality, and defensible medical decision-making, effective utilization controls, and appropriate care delivery within a rapidly evolving regulatory environment.

Partners with executive leadership, clinical teams, and external stakeholders to improve outcomes, support regulatory compliance, and advance organizational goals.

Duties

Provide executive clinical leadership in the development, review, approval, and ongoing oversight of clinical policies and coverage criteria to support consistent, appropriate, and evidence-based medical decision-making across Health Services.

Ensure all clinical policies comply with applicable federal, state, and accreditation requirements and are clearly documented, transparent, and consistently applied through standardized governance processes.

Monitor emerging medical technologies, procedures, evidence-based practices, and external benchmarks, including competitor policies, to identify the need for new or revised policies aligned with organizational strategy.

Provide strategic oversight of benefit design and clinical architecture to ensure clinical concepts are accurately translated into coding and authorization frameworks through collaboration with internal teams.

Validate codes, rules, and clinical logic are appropriately aligned and consistently applied across systems without direct involvement in system build activities.

Oversee authorization matrix strategy and governance by defining and approving regulatory authorization exemptions and ensuring alignment with state, federal, and accreditation requirements.

Provide clinical direction for prior authorization requirements and establish and approve performance metrics to evaluate internal and delegated clinical decision-making accuracy, timeliness, and consistency.

Oversee the Clinical Criteria Hierarchy, including approval of internal authorization and pre-payment review policies designed to mitigate fraud, waste, and abuse (FWA) risk and manage financial exposure.

Guide the strategic development of pre-payment review approaches to ensure appropriate fiscal and utilization oversight while maintaining regulatory compliance and access to care.

Duties Continued

Oversee service-level utilization tracking and analysis by establishing utilization benchmarks for core services and reviewing over- and under-utilization trends.

Use data-driven insights to identify drivers of aberrant utilization and approve mitigation strategies that may include policy refinement, provider education, benefit design adjustments, or modification of authorization requirements.

Partner with internal stakeholders to ensure policies support appropriate care delivery and align with utilization management strategies, product development, and medical economics.

Provide subject matter expertise and education related to new or revised policies and collaborate with operational teams to facilitate implementation that minimizes administrative burden on providers.

Ensure adherence to federal, state, and local regulatory requirements and accreditation standards and provide executive oversight of audits, regulatory inquiries, compliance reviews, and corrective action plans, including Participating Physician Group (PPG) remediation.

Work cross-functionally with internal departments to ensure clinical policies are clinically sound, operationally feasible, and well-received by internal and external stakeholders.

Serve as a subject matter expert for internal teams and external partners, mentor and guide clinical staff in policy interpretation and application and provide leadership to support consistent implementation across the organization.

Analyze claims data, utilization trends, and clinical outcomes to evaluate the impact of medical policies and prior authorization requirements and approve evidence-based recommendations to refine utilization management strategies.

Co-chair the Utilization Management Committee and participate in key organizational committees and governance forums.

Develop, approve, and update medical policies, procedures, and standards of care based on current, evidence-based practices.

Guide quality assurance and performance improvement (QAPI) programs and participate in quality review committees.

Assist in the preparation and monitoring of departmental budgets, including managing costs and resource utilization.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 8 years of experience in managed care, clinical policy development, or utilization management leadership.

Extensive post-medical degree experience in clinical practice.

Significant experience in a clinical development, medical affairs, or management role within the biotech, pharmaceutical, or healthcare industry.

Proven experience in a physician leadership role, including managing teams.

Preferred: 

Experience with Medicaid managed care and/or governmental programs for underserved, safety net populations including women, children, person with disabilities, seniors, and those of varied ethnic and cultural backgrounds. 

Skills

Required:

Strategic analytical thinker and the ability to interpret and apply clinical, utilization, and financial data.

Ability to balance clinical quality and cost-effectiveness.

Excellent written and verbal communication skills with the ability to effectively collaborate with multidisciplinary teams and senior leadership.

Strong leadership, consensus-building, and stakeholder engagement skills with strong commitment to evidence-based practice, continuous quality improvement, regulatory compliance, and health equity.

Demonstrated ability for teamwork and collaborative problem-solving, with a data-driven approach to evaluating programs.  

Ability to work collaboratively internally and externally to achieve results and apply negotiation skills.

Demonstrated commitment to delivering patient-centered, value-based care.

Knowledge of applicable regulatory and accreditation standards, including Centers for Medicare and Medicaid Services (CMS), Medi-Cal, Department of Managed Health Care (DMHC), and National Committee for Quality Assurance (NCQA).

Strong leadership presence with the ability to lead, mentor, and motivate a team.

Exceptional presentation skills to effectively convey complex medical concepts to diverse audiences.

Ability to work in a fast-paced, dynamic, and often ambiguous environment.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information