Medical Director – Population Health and Clinical Oversight

Key Accountabilities

Population Health Clinical Oversight and Strategy (45%)

• Provide physician leadership for population health priorities, with a focus on high-risk and high-cost populations across lines of business.
• Ensure the clinical appropriateness of risk stratification and intervention approaches, informing where and how resources are deployed.
• Guide clinical priorities that improve outcomes, experience, and value across targeted populations, aligned to client and contractual goals.

High-Cost Claimant and Stop-Loss Clinical Oversight (30%)

• Provide physician oversight for high-cost claimants and stop-loss reporting where required for contractual, audit, or customer needs.
• Ensure clinical validity, accuracy, and consistency of external reporting and client deliverables.
• Partner with analytics teams to streamline and standardize reporting processes, reducing manual physician involvement over time while maintaining clinical integrity.

Targeted Clinical Governance and Escalation (15%)

• Serve as the physician escalation point for complex, high-risk, or clinically ambiguous cases where physician input drives meaningful decisions or risk mitigation.
• Define and refine criteria for physician involvement so effort is focused on high-impact scenarios rather than broad retrospective review.
• Promote standards of practice, quality oversight, and exception-based engagement models that emphasize proactive, value-added physician review.

Physician Role Optimization and Work Reduction (10%)

• Identify and eliminate low-value physician work through automation, delegation, and clearer protocols, in partnership with operations and product teams.
• Lead the transition from legacy case management support toward a focused, high-impact physician role concentrated on population health, governance, and critical escalations.

A Day in the Life

• Provide real-time clinical guidance on prioritized high-cost claimants, escalated cases, and population health initiatives, collaborating with clinical operations, care management, and analytics teams.
• Review and validate clinical components of high-cost claimant and stop-loss reporting, ensuring outputs are accurate, defensible, and consistent with contractual obligations.
• Participate in cross-functional forums to set and refine population health strategies, including stratification criteria, intervention design, and outcome measurement.
• Serve as the final clinical decision-maker for complex or high-risk member scenarios, balancing evidence-based guidelines, member needs, and client expectations.
• Partner with operations and product teams to identify opportunities for automation, delegation, and protocol improvement to optimize physician work.