Director, Medical Policy

Location: Research Triangle Park, NC or Charlotte, NC

Position Purpose:  Join Carolina Complete Health Network in building an organization in which our team exceeds our stakeholders’ expectations and our Pay for Performance model will reward team members who continuously do so.

Reporting to the Chief Executive Officer (CEO), direct and coordinate Carolina Complete Health Network’s medical policy function.

  • Directs and coordinates the process to develop medical policies.
  • Works with Carolina Complete Health Network’s CEO and Carolina Complete Health’s Chief Medical Officer to coordinate the activities of the advisory committees established by Carolina Complete Health’s Medical Affairs Committee; including committee structure, processes, and membership.
  • Assists Carolina Complete Health Network’s CEO and Carolina Complete Health’s Chief Medical Officer in planning and establishing goals and policies to improve cost-effectiveness of care and service for members.
  • Facilitates the adoption of clinical practice guidelines.
  • Collaborates with health plan, internal, and external stakeholders to develop policy agendas.
  • Provides medical leadership for utilization management, cost containment, and medical quality improvement activities.
  • Assists in performing medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
  • Supports effective implementation of performance improvement initiatives for providers of the healthcare network.
  • Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, health plan, and accreditation requirements.
  • Directs the development and implementation of physician education with respect to clinical issues and policies.
  • Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
  • Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
  • Interfaces with physicians and other providers in the provider network in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.


Minimum Qualifications:

  • Nurse Practitioner, Registered Nurse or Physician Assistant.
  • Active state medical license without restrictions.
  • Course work in the areas of Health Administration, Health Financing, Insurance, preferred.
  • Experience treating or managing the care for a culturally diverse population preferred.
  • Previous experience with managed care organization preferred.
  • 10+ years of experience.

This position has been filled. Would you like to see our other open positions?