Medicare Medical Director – Philadelphia, Pennsylvania

The French Group has been retained by our client, an award-winning not-for-profit health plan, to identify a Medicare Medical Director.

Job Summary

The Medical Director will function as an integral part of the Health Care Senior Management team with responsibility for care management, quality management and pharmacy services programs. This position will focus on Medicare and Medicare Advantage, but may also be involved with other product lines and services which have attracted seniors or disabled individuals. This position will represent Health Care Management in interdepartmental activities and represent the Plan in the health system and provider communities as well as in regulatory and governmental activities.  The Medical Director will apply clinical expertise and experience as a provider to promote the appropriate delivery of medically necessary services to the population served.  She/he will perform utilization, pharmacy and quality reviews and will analyze and profile utilization patterns in order to meet with and direct network providers. The Medical Director will also be very familiar with Medicare regulations and provide expertise and support to the Stars program and accurate acuity scoring efforts.

Primary Responsibilities

  • Provide utilization management services and advise the Health Care Senior Management team regarding the utilization of health care services and interventions, disease management and case management services to promote the effective delivery of medically necessary services.
  • Serve on and support the functions of the Utilization Management Committee, Credentialing Committee, Pharmacy & Therapeutics Committee, and the Quality Management Committee.
  • Serve as a resource to the Finance Department in evaluating present utilization experience and projecting future utilization patterns.
  • Provide leadership for Plan accreditation processes (NCQA), Stars, Utilization, Quality and Disease Management programs.
  • Develop and or revise practice guidelines for acute and chronic care.
  • Develop and implement policies and procedures required to promote effective utilization management and achieve established targets.
  • Collaborate with Health Care Economics and Finance to continuously improve the collection and use of data describing resource utilization, outcomes and acuity scoring.
  • Represent Health Care Management internally and externally at the direction of the Chief Clinical Officer.
  • Develop and implement work plans to optimize appropriate utilization and quality targets as directed by the Chief Clinical Officer.


  • MD or DO with active, unrestricted Pennsylvania medical license plus MBA/MPH desirable
  • Current board certification in ABMS recognized specialty; primary care preferred
  • Minimum 5 years post-residency experience in the clinical practice of medicine, preferably with management responsibility.
  • Minimum 3 years of experience in a managed care setting, preferably with responsibility for utilization management.
  • Strong familiarity with Medicare, Medicare Advantage, utilization analytics and management as well as familiarity with federal regulations relating to utilization management activities is required.
  • Excellent organizational, interpersonal, time management and communication skills.
  • Exceptional leadership and project management skills.
  • Strong conflict resolution and independent decision-making skills.
  • Excellent influencing, negotiation and analytical skills.
  • Knowledge of the principles of Quality and Care Management.

For additional information and/or confidential consideration, please contact:

Tricia French, RN, BSN
President & CEO
The French Group