Medical Director
Req number:
R8700
Employment type:
Full time
Worksite flexibility:
Remote
Job Summary
As the Medical Director, you will ensure utilization management responsibilities are performed in accordance with the highest and most current clinical standards.
Job Description
We are looking for aMedical Directorto ensureutilization managementresponsibilities are performed in accordance with the highest and most current clinical standards. This position will befull-timeandremote.
What You9ll Do
- Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer-to-peer discussions, to determine medical necessity and appropriateness
- Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned
- Compose clear and concise rationales for members and provider determination notifications while adhering to required compliance standards (NCQA,URAC,CMS,DOH, andDOLregulations, etc.)
- Ensure that all aspects of the medical management process are consistent with community standards of care
- Participate as a member of the CMDM multidisciplinary team: attend huddles and grand rounds, and advise the multidisciplinary team on cases requiring physician expertise
- Participate in protocol and guidelines development to ensure consistency in the review process
- Actively manage projects and/or participate on project teams that require a physician subject matter expert
What You9ll Need
Required:
- Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
- Awarded Board Certification at least once in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
- Active medical state licensure required for PA, NY, or WV
- 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
- Strong skills inCritical Thinking,Case Management,Customer Service,Oral & Written Communication,Collaboration,Listening,Telephone Skills,General Computer Skills,Clinical Software, andManaged Care
Preferred:
- Master9s Degree in Business Administration/Management or Public Health
- 1 year in Medical Management in a Health Insurance Plan; strong knowledge ofmanaged careindustry
- Experience withMCGorInterQual
Physical Demands
- Ability to safely and successfully perform the essential job functions consistent with the ADA and other federal, state, and local standards
- Ability to conduct repetitive tasks on a computer, utilizing a mouse, keyboard, and monitor
- Must be able to communicate with customers/team members over the phone and in person
- Sedentary work that involves sitting or remaining stationary most of the time with occasional need to move around the office to attend meetings, etc.
#LI-AL2
$170-$200 per hour
The pay range for this position is listed above.Exact compensation may vary based on several factors, including location, experience, and education. Benefit packages include medical, dental, and vision insurance, as well as 401k retirement account access. Employees in this role may also be entitled to paid sick leave and/or other paid time off as provided by applicable law.
