Director, State RAC Medical

Great companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development. 

Summary

We are seeking a talented individual for a Medical Director who provides clinical leadership and direction for projects and contracts in support of the Corporate Mission, Vision, and Values.  The Medical Director also has responsibilities for Quality of Care, Peer Review, Clinical Expertise, Program Management and Development, Physician Review Panels, Quality of Care Review, Outcome Measurement Programs, HIPAA Privacy Expertise, Utilization Review, HIPAA Compliance, and Quality Assurance. 

Your role in our mission

• Manages all aspects of Recovery Audit Program including audit review and appeal process, provider education and training, quality assurance, literature research, and hearing support.
• Provides clinical perspective and input to product development.
• Coordinates activities of employed physician reviewers, part time and contract physician reviewers, and assistant Medical Directors.
• Provides clinical expertise and support to corporate clients.
• Analyzes health care data for new market development, current operations, utilization management, fraud waste & abuse.
• Represents the organization in client presentations and responses to audits.
• Supports the organizations' government and commercial clients in formal and informal hearings.
• Provides clinical expertise to project teams as requested.
• Represents the organization at contract/customer meetings to advocate for clinically relevant and economically feasible project studies.
• Presents results of projects to relevant audiences to demonstrate the organization's position as a leader in Payment Integrity.
• Performs literature searches as indicated to determine appropriateness of review decisions, to determine experimental status, and to determine cosmetic versus medical necessity issues.
• Interacts with reviewers to clarify clinical issues, administrative issues, and scientific issues as they apply to specific reviews.
• Monitors quality of reviewers and reviews for timeliness, completeness, and process compliance, while assuring appropriate levels of productivity and efficiency. 
• Participates on quality improvement teams in support of Quality Assurance as assigned.

What we're looking for

• A minimum of five (5) years of experience in utilization review.
• Must hold an active license (MD or DO), in good-standing. May require additional state specific medical licensure if needed.
• Graduate of an approved school of either Medicine or Osteopathy required. Completed accredited residency in United States (or equivalent) residency program.
• Five (5) years of experience in active practice.
• Proficiency in creating, querying, and analyzing reports.
• Experience and proficiency with InterQual and Milliman Care Guidelines.
• Medium skill set with computer and software usage.
• Strong writing skills with the ability to convey data in a clear and actionable manner.
• Demonstrated expertise and knowledge able to apply commercially available utilization guidelines such as InterQual or MCG.

What you should expect in this role

• May be required to work extended hours for special business needs.
• May be required to travel at least 10% of time based on business needs.

The deadline to submit applications for this posting is June 2, 2025.

The pay range for this position is $179,500.00 - $256,400.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.