Medical Director – Population Health and Clinical Oversight

The Medical Director – Population Health and Clinical Oversight provides physician leadership focused on population health strategy, high-cost claimant and stop-loss oversight, and targeted clinical decision support across Transcarent’s clinical programs. This role ensures that clinical models are sound, risk is appropriately managed, and physician involvement is concentrated where it delivers meaningful clinical and financial impact.

Reporting to senior clinical leadership, the Medical Director partners closely with operations, analytics, and product teams to guide population health priorities, streamline physician workflows, and uphold the highest standards of clinical quality and governance.

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, product, and technology to redesign workflows and clinical policies that reduce unnecessary physician touchpoints while preserving or enhancing clinical quality.
• Monitor emerging trends in clinical utilization, risk, and outcomes to identify opportunities for model evolution, workflow simplification, and physician work reduction.

What We Are Looking For

Education & Experience

• Education: Doctor of Medicine (MD) or Doctor of Osteopathy (DO) degree; current, unrestricted medical license in good standing. Board certification in an applicable specialty (e.g., Internal Medicine, Family Medicine, Emergency Medicine, or relevant subspecialty) required.

Experience:

• 7+ years of clinical practice experience, with at least 3–5 years in a health plan, population health, accountable care, or value-based care setting.
• Demonstrated experience with population health management, high-cost claimant oversight, or utilization management programs.
• Prior leadership experience in a medical director or equivalent physician leadership role strongly preferred.

Clinical & Domain Expertise

• Deep understanding of population health concepts, including risk stratification, targeted interventions, and measurement of clinical and financial outcomes across populations.
• Familiarity with high-cost claimants, stop-loss programs, and clinical risk management, including how clinical oversight influences contractual performance and client satisfaction.
• Experience in clinical governance and quality oversight, including setting clinical standards, review criteria, and escalation pathways for complex cases.
• Comfort working with analytics, reporting outputs, and data-driven decision-making in a clinical or operational context.

Professional Competencies

• Strategic Clinical Leadership: Ability to connect day-to-day clinical decisions and governance activities to broader population health, contractual, and business objectives.
• Analytical Judgment: Strong clinical reasoning skills with the ability to interpret complex medical histories, utilization patterns, and outcomes data to guide high-stakes decisions.
• Stakeholder Communication: Proven ability to translate clinical and analytic insights into clear, actionable guidance for non-physician stakeholders, including operations, clients, and executive leaders.
• Change Management & Influence: Comfortable leading change across multidisciplinary teams, including evolving physician roles, workflows, and review criteria.
• Collaboration: Effective collaborator in a matrixed environment, able to align clinical, operational, analytic, and product stakeholders around shared goals.
• Operational Discipline: High attention to detail and consistency in clinical decision-making, documentation, and review processes, recognizing the contractual and member implications of physician judgments.
• Innovation & Continuous Improvement: Mindset focused on simplifying processes, reducing low-value work, and continuously improving clinical models and workflows over time.