Health Plan Medical Director, Medicare Advantage
Your Medicare Advantage plan needs a physician leader who can defend coverage decisions, guide reviewers, and reduce avoidable appeal risk.
No upfront fee. You pay only if you hire.
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What does this hire really come down to?
A Health Plan Medical Director reviews difficult authorization and appeal files, speaks with treating physicians, interprets medical policy, and directs clinical review decisions. The work may include a disputed inpatient stay in the morning, a committee packet in the afternoon, and coaching on case notes before close.
Strong clinical practice alone does not prove payer readiness. This physician must read records against InterQual or MCG criteria, identify what is missing, weigh new evidence, and record a rationale that another reviewer can follow. We ask how candidates separate documented facts from a provider’s urgency, a pending deadline, or pressure to reach a preferred outcome.
Define authority before interviews start. One plan may need a physician focused on difficult cases, peer discussions, and appeals committees. Another may need a direct leader for nurses, physician reviewers, and coordinators. We screen against your reporting line, decision rights, and actual case mix rather than assuming an experienced physician wants every part of the role.
What do we ask candidates about?
- License and board status. We screen for an active, unrestricted medical license and current board certification in primary care or a high-volume specialty. We ask where the physician holds licenses, what states matter to you, and how recent clinical credentials have been maintained. Your team completes final credentialing and clinical assessment.
- Criteria-based case review. We ask for a recent example involving InterQual or MCG criteria. A credible answer identifies the records reviewed, the criterion in question, what documentation was absent, and the rationale entered after the review.
- CMS and NCQA experience. We explore CMS standards, NCQA reviews, audits, corrective action work, and delegated functions when relevant. We ask what the candidate did when a file review found late notices, uneven rationale, or incomplete records.
- Peer discussion judgment. We use a hypothetical physician who presents new facts during a disputed review. We listen for clear questions, attention to the record, a reasoned response, and notes explaining whether the new information changed the decision.
- Appeals and policy work. We ask whether the physician has prepared matters for internal committees, external review, or legal review. The answer should connect plan language, clinical evidence, timelines, and the member record without extending beyond known facts.
- Team leadership, risk adjustment, and quality. Where staff management is part of the post, we ask how the candidate coaches nurses and reviewers on case notes and calibration. We also ask how they discussed risk adjustment, quality measures, and documentation patterns with network providers.
We discuss experience and qualifications. Your team assesses clinical ability and completes the credential checks before hiring.
Where do we look, and why would they move?
We recruit physicians from group practices, academic health systems, and provider organizations where they worked as physician advisors, quality leaders, or medical staff leaders. Some consider plan work after seeing repeated documentation gaps, inconsistent case decisions, or disconnected handoffs between care settings. Others want less direct patient care and broader influence on review decisions.
We also speak with medical directors and clinical leaders from managed care organizations, payer service organizations, and delegated medical groups. A physician may seek broader policy input, a different reporting structure, or more direct responsibility for appeals. We ask why they are open to a move, what authority they hold now, and which cases they still review.
Which mistakes stall the search?
Hiring a respected practicing physician without testing recent Medicare Advantage case review, appeals, criteria, and policy experience.
Leaving reporting lines vague, then discovering the post includes staff supervision or committee duties the candidate does not want.
Treating provider communication as secondary, even though unclear peer discussions can trigger repeat escalations and weak case records.
How does your search work?
Tell us who you need
We ask about the job, your team, the requirements and what you can offer.
We find and contact people
We research suitable backgrounds and speak with candidates about their experience and interest.
You meet the strongest candidates
We explain why we recommend each person and arrange introductions for your interviews.
We help you complete the hire
We help with feedback, the offer, notice and practical questions before the start.
Tell us the job, setting and location. We will discuss your requirements and the terms before a search begins.
What happens next
- The initial conversation clarifies the work, location and search terms.
- Ivan or a senior team member will reach out soon.
- When we recommend someone, you get reasons for fit and open questions to assess. We support interviews and offer discussions.
- Fees.
- No upfront fee. Pay only if you hire, under the signed agreement.
- Exclusivity.
- Set out in the signed client agreement.
- Confidentiality.
- We agree the brief before outreach. This is not a promise of absolute anonymity.
- No hire.
- No hire means no fee on standard searches.
The role and the setting
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What do employers ask us?
Must this Medical Director hold an active medical license?
Yes: we screen for an active, unrestricted medical license and current board certification in primary care or a high-volume specialty. Your organization decides which state licenses apply and completes its own credentialing.
How much InterQual or MCG experience should we seek?
Look for recent, direct use rather than name recognition. We ask how candidates handled incomplete records, conflicting documentation, and disagreement from a treating physician.
Should this physician directly manage the review team?
That depends on your structure. Some plans need a director for difficult cases and committees, while others need a leader who coaches nurses, physician reviewers, and coordinators. Set that scope before first interviews.
How can we test CMS and NCQA knowledge without a theoretical interview?
Ask about an audit, file review, policy revision, or corrective action from prior work. We probe for the issue found, the candidate’s own contribution, and what changed afterward.
What are the fee arrangements for this search?
No upfront fee. No upfront fee. You pay only if you hire. We offer a candidate replacement guarantee on standard search agreements. The applicable period and exact terms are set out in the signed client recruiting agreement. Permanent/direct-hire recruitment is our core service across clinical, operational and leadership roles. If you need a temporary or other arrangement, describe the need so we can discuss whether we can help. Responsibilities and terms must be confirmed separately for that engagement. Your organization retains clinical assessment and credentialing responsibility.
What should you send us about this role?
Send us the role, where the person will work and what needs to change with this hire. We will ask about the work, not just the title. Share any license or schedule limits that could rule someone out before we begin the search.
If you need a Medicare Advantage Medical Director who can defend case decisions and lead clinical review work, Healthcare Headhunters can start with your authority scope, reporting structure, and selection process.
No upfront fee. You pay only if you hire. We offer a candidate replacement guarantee on standard search agreements. The applicable period and exact terms are set out in the signed client recruiting agreement.
What happens next
- The initial conversation clarifies the work, location and search terms.
- Ivan or a senior team member will reach out soon.
- When we recommend someone, you get reasons for fit and open questions to assess. We support interviews and offer discussions.
- Fees.
- No upfront fee. Pay only if you hire, under the signed agreement.
- Exclusivity.
- Set out in the signed client agreement.
- Confidentiality.
- We agree the brief before outreach. This is not a promise of absolute anonymity.
- No hire.
- No hire means no fee on standard searches.