JOB SUMMARY

eviCore Business Title: Medical Director, Post-Acute Care  

 Cigna Title: Utilization Review Medical Principal

II.          Department Name and Number: Product Clinical Management 2500

III.        Reports to: Executive Medical Director, Post Acute Care or Program Chief

Summary:

The Medical Director provides timely expert medical review of medical necessity requests for clinical services that do not meet utilization review criteria and renders a clinical opinion about the medical service under review while located in a state or territory of the United States.

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Responsibilities include:

• Provide timely expert medical review of medical necessity requests for clinical services related to post acute care and render a clinical opinion about the medical service under review, including post-decision reviews.
• Provide timely and collegial peer-to-peer discussions with treating physicians to clarify clinical information and to explain review outcome decisions.
• Participate in proactive peer to peers to assist with appropriate and timely discharge planning.
• Document all actions related to clinical review sessions and attest to review qualifications as required.
• Conduct weekly Case Conferences with nursing and social worker teams; discussing every assigned member receiving care in a post-acute care facility, focusing on discharge planning, complex medical care management, quality of care, appropriate level of care, and appropriate length of stay.
• Maintain necessary credentials and immediately inform eviCore of any adverse actions relating to medical licenses and/or board certifications.
• Support the review of eviCore clinical guidelines.
• Support and communicate eviCore policies and procedures to the provider community.
• Testify at ALJ Hearings when your cases are being appealed
• Assist with staff educational training and in-service programs and serve as a clinical resource for eviCore staff.
• Serve as a Subject Matter Expert when Medical Directors and/or Senior Medical Directors are unavailable.
• Available for scheduled weekend call from home based on business needs.
• Participate in Joint Operating Committee (JOC) meetings, including the collection and review of data relevant to the client, and other virtual events with the provider engagement team in your specified territory.
• Participate in all required educational and quality improvement activities and maintain passing scores in all assessments.
• Assist in reviewing case determinations from clients responding to a provider or member complaint
• Maintain necessary credentials and immediately inform eviCore of any adverse actions relating to medical licenses and/or board certifications
• Other duties as assigned

Minimum Education, Licensure and Professional Certification requirement:

• M.D. or D.O. degree from accredited institution.
• Minimum of five (5) years of clinical practice experience after completion of all graduate medical education training, including residency and fellowship (when applicable)
• Active board certification in Physical Medicine and Rehabilitation
• Active unrestricted license to practice medicine in a state or territory of the United States as a utilization review doctor of medicine or doctor of osteopathic medicine.
• Knowledge of applicable state and federal laws, URAC and NCQA standards, and utilization management

Competencies:

• Decision Quality
• Persuades
• Interpersonal Savvy
• Manages Conflict
• Self-Development

FLSA (Exempt or Non-Exempt) : Exempt

Bonus Type: (Indicate which option is applicable) :

• Corporate Incentive Plan - CIP (Exempt Team Members)
• Corporate Success Share Plan - SHARE (Non-Exempt Team Members)
• Department Incentive Plan  
• Quarterly
• Monthly

Status:  Full time, 1.0 FTE and 5 days/week schedule

Required Skills: Must be able to type 30 WPM, be proficient computer skills and knowledge of Microsoft Office applications

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 207,800 - 346,300 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 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 and paid holidays. For more details on our employee benefits programs, click here.