Medical Director
Overview
We are seeking a Neonatologist Reviewing Medical Director to provide specialized clinical leadership for Neonatal Intensive Care Unit (NICU) utilization management and neonatal clinical operations. This virtual role is responsible for reviewing complex NICU cases, applying evidence-based medical necessity criteria, supporting Medicaid neonatal programs, and collaborating with providers and internal teams to ensure high-quality care for newborns and infants. The ideal candidate is a board-certified Neonatologist with strong NICU utilization management experience, deep clinical expertise, and the ability to make timely, consistent, and well-supported medical necessity determinations.
Responsibilities
NICU Clinical Review & Medical Necessity Determinations Review and evaluate NICU admissions, continued stays, level-of-care requests, transfers, and discharge-related services. Assess maternal, delivery, newborn, and NICU clinical documentation for medically complex neonates and critically ill newborns. Apply evidence-based clinical guidelines, coverage criteria, and Medicaid requirements when making determinations. Document clear and clinically supported medical necessity rationales. Evaluate gestational age, postmenstrual age, respiratory support, nutrition support, acuity, treatment needs, and discharge readiness. Support physician-level review of DRG validation and NICU level-of-care determinations. Prioritize reviews to meet regulatory, contractual, and operational turnaround requirements. Escalate complex or high-risk cases according to established policies. Clinical Operations & Medicaid Support Maintain expertise in federal Medicaid regulations, state-specific requirements, and neonatal clinical policies. Support consistent application of neonatal utilization management standards across assigned states. Participate in neonatal quality improvement, care management, discharge planning, and clinical initiatives. Provide clinical expertise and guidance to internal teams regarding neonatal services. Physician Collaboration & Peer Reviews Conduct peer-to-peer discussions with: Neonatologists Pediatric specialists Hospital-based physicians Treating providers Gather additional clinical information and discuss review outcomes. Manage complex clinical conversations professionally and effectively. Collaborate with providers, facilities, care management teams, and community stakeholders to support neonatal outcomes and care transitions. Team & Coverage Responsibilities Provide cross-coverage support during planned absences, holidays, weekends, and peak workload periods. Collaborate with medical directors, neonatal clinical teams, and operational partners to ensure consistency in review practices. Promote ethical decision-making, regulatory compliance, and patient-centered care.
Required Qualifications
Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO). Board Certification in Neonatal-Perinatal Medicine recognized by the American Board of Pediatrics. Active, unrestricted medical license in Oklahoma and/or South Carolina . Ability to obtain and maintain additional state licenses as required. Minimum 5 years of post-training clinical practice experience in Neonatal-Perinatal Medicine. Recent experience providing direct patient care within a NICU environment. Experience conducting NICU utilization management reviews in: Health plans Independent review organizations Hospital environments Comparable payer or clinical settings Ability to meet credentialing requirements. No current federal or state sanctions.
Preferred Qualifications
Experience working with Medicaid populations and neonatal services. Experience supporting: NICU case management Concurrent review Prior authorization Appeals Peer-to-peer review Utilization management operations Familiarity with healthcare quality accreditation standards. Experience with utilization management platforms such as: MHK CGX Comparable systems Participation in or eligibility for the Interstate Medical Licensure Compact. Key Skills Neonatal Intensive Care (NICU) Neonatal-Perinatal Medicine Utilization Management Medical Necessity Reviews Medicaid Clinical Operations Peer-to-Peer Reviews Level of Care Determinations DRG Validation Clinical Documentation Review Appeals & Prior Authorization Quality Improvement Regulatory Compliance Provider Collaboration