Medical Director - SummaCare

Medical Director - SummaCare SummaCare - 1200 E Market St, Akron, OH Full-Time / 40 Hours / Days Hybrid SummaCare Health Plan is seeking an experienced, board-certified physician to join our team as a Medical Director. In this hybrid role, you will apply your clinical expertise to ensure our members receive medically appropriate, high-quality care while supporting the organization's mission to deliver accessible, cost-effective health services to the communities we serve. The primary focus of this position is hands-on clinical chart review and medical necessity determination, including prior authorization, concurrent review, retrospective review, and appeals adjudication. The remainder of your time will be dedicated to key administrative and leadership responsibilities that directly support quality improvement, pharmacy oversight, program integrity, and cross-departmental medical guidance. Summary: Provides leadership and oversight of clinical services, medical economics, and medical director team, bringing practice perspectives to all programs and initiatives. Partner with other departments - including Care Management, Quality Improvement, Pharmacy, Provider Relations, and Compliance - to provide medical oversight, clinical consultation, and physician expertise on cross-functional initiatives and programs. Formal Education Required: a. Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited institution. b. Current, unrestricted license to practice medicine in the State of Ohio. c. Board certification in a relevant specialty (e.g., Internal Medicine, Family Medicine, Emergency Medicine, or a related clinical discipline). Experience & Training Required: a. Five (5) years of clinical practice experience in direct patient care. Essential Functions: 1) Conduct thorough, timely review of submitted medical records and clinical documentation to make medical necessity determinations for prior authorization, concurrent review, and retrospective review requests across all lines of business. 2) Apply evidence-based clinical guidelines - including MCG, InterQual, and national coverage determinations - to evaluate requests for inpatient admissions, outpatient services, specialty care, procedures, and durable medical equipment. 3) Perform physician-level review of complex, unusual, and clinically ambiguous cases, exercising sound clinical judgment based on established criteria, member-specific clinical facts, and SummaCare medical policies. 4) Review and adjudicate member and provider appeals and grievances in a timely, compliant manner, ensuring all determinations are well-documented, evidence-based, and aligned with regulatory requirements. 5) Conduct peer-to-peer discussions with treating physicians, specialists, and facility-based providers to gather additional clinical information, discuss care plans, and communicate coverage determinations professionally and collaboratively. 6) Identify and evaluate adverse utilization trends, unusual provider practice patterns, and comparative utilization differences across lines of business, geographic regions, and employer groups; escalate findings as appropriate. 7) Provide medical consultation on complex or controversial claims that fall outside the scope of established medical policy, including experimental, investigational, and innovative treatment requests; solicit expert input from external medical consultants when indicated. 8) Oversee development and maintenance of preadmission certification protocols, length-of-stay guidelines, and concurrent and retrospective review criteria, ensuring alignment with current clinical evidence. 9) Review cases involving potential quality-of-care concerns and collaborate with the Quality Improvement team to ensure timely investigation and follow-up. 10) Maintain productivity and turnaround time standards for all clinical review work in accordance with NCQA, URAC, CMS, and Ohio Department of Insurance requirements. 11) Performs all job functions with integrity. Provides timely internal and external customer service in cooperative, professional and respectful manner. Other Skills, Competencies and Qualifications: a. Strong understanding of healthcare economics and the medical economics of managed care. b. Proficiency with national clinical guidelines, CMS policies, and regulatory and accrediting standards (NCQA, URAC). c. Ability to travel from location to location throughout the workday. d. Clinical Excellence: Applies broad, up-to-date clinical knowledge to evaluate complex, multifactorial cases accurately and consistently. e. Analytical Thinking: Designs, develops, and interprets data related to utilization trends, clinical outcomes, and medical policy to drive evidence-based decisions at an organizational level. f. Communication: Communicates complex clinical and policy information - in verbal and written form - clearly and effectively with diverse audiences, including front-line clinical staff, senior leadership, regulatory bodies, and board members. g. Collaboration & Influence: Partners effectively with physicians, nurses, administrators, and business leaders; able to negotiate, persuade, and build consensus across organizational levels. h. Regulatory Knowledge: Maintains current expertise in federal and state healthcare regulations, accreditation standards, and managed care compliance requirements. i. Integrity & Confidentiality: Handles all patient and business information with strict confidentiality and exercises sound professional judgment in all interactions. j. Adaptability: Adjusts priorities and work approach to meet evolving business demands in a fast-paced managed care environment. Level of Physical Demands: a. Ability to sit for prolonged periods while conducting computer-based chart review. b. Manual dexterity sufficient to operate a computer, phone, and standard office equipment. c. Occasional lifting of up to 20 pounds. d. Ability to bend, stoop, and stretch as required in an office setting. e. Must be able to work core business hours, Monday through Friday, with flexibility to meet organizational needs. Based in Akron, Ohio, SummaCare provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2026 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits. Equal Opportunity Employer/Veterans/Disabled $106.72/hr - $160.07/hr The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical. Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other benefits. * Basic Life and Accidental Death & Dismemberment (AD&D) * Supplemental Life and AD&D * Dependent Life Insurance * Short-Term and Long-Term Disability * Accident Insurance, Hospital Indemnity, and Critical Illness * Retirement Savings Plan * Flexible Spending Accounts - Healthcare and Dependent Care * Employee Assistance Program (EAP) * Identity Theft Protection * Pet Insurance * Education Assistance * Daily Pay

Created: 2026-04-15