Medical Director

The job profile for this position is Medical Director, which is a Band 5 Management Career Track Role.

Medical Director: Inpatient Utilization and Population Management

ABOUT OUR TEAM: We pride ourselves on being trusted clinical leaders and subject matter experts in the market and across the enterprise. Our customers and patients are at the center of all we do as we partner with providers, customers, and internal colleagues to drive toward the best clinical outcomes Are you ready to make an impact?

POSITION SUMMARY: As an Inpatient Medical Director, you'll provide critical clinical insight across the enterprise supporting the effectuation of MCG guidelines for level of care appropriateness You'll have the opportunity to partner with leaders across all business units including Express Scripts and Evernorth to develop solutions to some of the greatest challenges in health care. As a manager of direct reports, a growth mindset and desire to lead are paramount.

WHAT YOU'LL DO:

• Lead a team of clinicians to deliver superior results for organization by supporting utilization management functions as well strategic clinical initiatives
• Perform benefit-driven medical necessity reviews for coverage, case management, and claims resolution as needed using benefit plan information, applicable federal and state regulations, clinical guidelines, and best practice principles
• Work to achieve quality outcomes for customers with a focus on service and cost
• Improve clinical outcomes through daily interactions with health care professionals using active listening, education, and excellent communication and negotiation skills
• Balance customer/member needs with business needs while serving as a customer advocate at all times
• Participate in all levels of the Appeal process as appropriate
• Participate in coverage guideline development, development, and maintenance of medical management projects, and quality committees
• Participate in quality processes such as reviews, inter-rater reliability clinical reviews, and quality projects
• Serve as a mentor or coach to other Medical Directors and other colleagues in quality and performance improvement processes.
• Improve health care professional relations through direct communication, knowledge of appropriate evidence-based clinical information, and the fostering of positive collegial relationships
• Address customer service issues with mentoring and support from leadership staff
• Investigate and respond to client and/or regulatory questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff
• Achieve internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions
• Provide clinical insight and management support to other functional areas and matrix partners as needed or directed
• Direct the medical management functions for a market, region, or national programs including overseeing utilization review and quality assurance, directing case management, developing medical policies and evaluating new technologies and treatments
• Operate as a senior clinician for a market, region or nationally where required
• Create and implement medical management strategic plans for a market, region or nationally
• Support network operations and act as physician liaison in community
• Investigate and respond to client questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff
• Achieve customer satisfaction by assuring both timely turn-around of coverage reviews and quality outcomes

WHAT YOU'LL BRING (minimum requirements):

• Current unrestricted medical license in a US state or territory
• Current board certification in an ABMS or AOA recognized specialty (grandfathered by the board or maintained by the MOC program)
• Ethical and professional behavior
• Minimum of 5 years of clinical practice experience and/or direct patient care beyond residency
• Computer Competency: Word processing, Spreadsheet, Email, and Personal Information Management programs are used extensively and competency in all must be possessed or rapidly acquired. Must be able to research clinical issues on internet resources
• Ability to travel to attend meetings in person as needed

PREFERRED SKILL SETS:

• At least three years' experience in medical management, utilization review and case management in a managed care setting
• Knowledge of Pharmacy Claims and utilization management is a plus
• Knowledge of Specialty Pharmaceuticals and management is a plus
• Previous experience managing physicians, nurses or employees is a plus but not required
• Experience in medical management, utilization review and case management in a managed care setting
• Knowledge of managed care products and strategies
• Ability to work within changing business environment and balance patient advocacy with business needs
• Experience with managing multiple projects in a fast-paced matrix environment
• Demonstrated ability to educate colleagues and staff members
• Successful experience and comfort with change management
• Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem solving skills
• Successful ability to assess complex issues, to determine and implement solutions, and resolve problems
• Success in creating and maintaining cooperative, successful relations with diverse internal and external stakeholders
• Demonstrated sensitivity to culturally diverse situations, participants, and customers/members
• Service marketing, sales, and business acumen experience a plus

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an annual salary of 230,600 - 384,400 USD / yearly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus and long term incentive plan.

At The Cigna Group, you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year, paid holidays, and leaves of absence. For more details on our employee benefits programs, click here.