Executive Medical Director DME/IRF

The Cigna Group

9d•$238,100 - $396,800•Remote

About The Position

The Medical Director DME & IRF oversees intraday activities of EviCore’s Durable Medical Equipment and Inpatient Rehabilitation Facility management programs and services. Responsibilities include serving as the program's internal lead for DME clinical guideline and policy management, working with the Guideline Manager to create EviCore DME guidelines, and maintaining and updating DME denial rationales. The role involves representing EviCore in audits or case discussions related to Medicare or Medicaid policies for DME and IRF issues, and collaborating with the pathways team to provide clinical support for the development of DME clinical pathways. The position also includes creating quarterly DME IRR quizzes, holding quarterly debriefs with physicians, and assisting in case audits to assess the accuracy of Associate Medical Directors’ and Medical Directors’ decision-making and adherence to EviCore criteria and processes. Regular 1:1 meetings with DME/IRF associate medical directors/medical directors are required, along with providing weekend coverage for urgent DME & IRF appeals. The role may involve testifying at ALJ Hearings and providing audit support for DME & IRF cases during CMS and client audits. Additionally, the Executive Medical Director will assist with interviewing, onboarding, and training new DME/IRF Associate Medical Directors, serving as a Subject Matter Expert and first point of contact for assistance with problematic or escalated cases. The position requires responding to urgent, expedited, or escalated DME and IRF cases and P2Ps, reviewing case determinations from clients, and responding to notifications to amend incorrect reviews. The Executive Medical Director manages the day-to-day clinical activities of the eviCore DME/IRF Program, collaborates with leadership from Clinical Operations, Non-clinical Operations, and Program Operations, and supervises and manages the activities of the DME/IRF program’s Medical Directors and Associate Medical Directors. This includes ensuring effective and objective application of clinical guidelines, accurate determination of medical necessity, and efficient processing of clinical case review requests. The role supports the development and maintenance of EviCore policies, procedures, and criteria related to clinical certification, and coordinates the clinical development and education of the DME/IRF program’s Medical Directors and Associate Medical Directors. Performance evaluation of these individuals is also a key responsibility, acting as a coach, mentor, and/or clinical supervisor. The position supports the review of EviCore clinical guidelines and serves as a clinical representative for designated programs when requested by the Program Chief. It involves providing timely expert medical review of medical necessity requests, rendering clinical opinions, and supporting timely completion of clinical cases. Maintaining necessary credentials and informing EviCore of any adverse actions is crucial. The role also involves supporting and communicating eviCore policies and procedures to the provider community and participating in all required educational and quality improvement activities.

Requirements

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 & 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
Two (2) or more years of managed care experience
Familiarity with automated processes and computer applications and systems also required

Nice To Haves

Supervisory and/or management experience strongly preferred

Responsibilities

Serve as program internal lead for DME clinical guideline and policy management
Work with Guideline Manager to create eviCore DME guidelines
Maintain and update DME denial rationales
Represent EviCore in audits or case discussions specifically arranged around Medicare or Medicaid policies regarding DME and IRF issues/decisions
Work with pathways team and provide clinical support for development of DME clinical pathways
Create quarterly DME IRR quiz and hold quarterly debrief with physicians after quiz is completed
Assist in case audits to assess the accuracy of Associate Medical Directors’ & Medical Directors’ decision making and adherence to the EviCore criteria and processes
Hold regular 1:1 meetings (alternating with program chief) with DME/IRF associate medical directors/medical directors
Provide weekend coverage to complete urgent DME & IRF appeals that cannot be completed by the on call PAC/DME associate medical director/medical director
Testify at ALJ Hearings when your cases are being appealed or adjudicating Associate Medical Director is unavailable
Provide audit support for DME & IRF cases reviewed during CMS and client audits
Assist with interviewing, onboarding, and training new DME/IRF Associate Medical directors
Serve as a Subject Matter Expert and first point of contact for Associate Medical Directors who are seeking assistance with problematic case reviews, or escalated cases that deserve immediate review and attention
Respond to urgent, expedited, or escalated DME and IRF cases and P2Ps
Assist in reviewing case determinations from clients responding to a provider or member complaint
Assist in responding to notifications and requests to amend incorrect reviews when the physician reviewer who initially reviewed the case is not available
Manage the day-to-day clinical activities of the eviCore DME/IRF Program
Collaborate with leadership from Clinical Operations, Non-clinical Operations, and Program Operations to support and promote optimal program functioning and identify opportunities for improvement
Supervise and manage activities of the DME/IRF program’s Medical Directors and Associate Medical Directors to ensure effective and objective application of clinical guidelines, accurate determination of medical necessity, and efficient processing of clinical case review requests in accordance with legal and contractual obligations
Support the development and maintenance EviCore policies and procedures and criteria related to clinical certification
Coordinate the clinical development and education of the DME/IRF program’s Medical Directors and Associate Medical Directors through collection/ circulation of educational materials, organization of quarterly educational sessions, and other activities as appropriate
Evaluate the performance of the DME/IRF program’s Medical Directors and Associate Medical Directors.
Serve as a coach, mentor, and/or clinical supervisor for specific Medical Directors and/or Associate Medical Directors
Support the review of EviCore clinical guidelines
Support sales and client management teams as clinical representative for designated program when requested by Program Chief
Provide timely expert medical review of medical necessity requests for clinical services and renders a clinical opinion about the medical service under review, including post-decision reviews, when necessary to support timely completion of clinical cases within the designated program
Maintain necessary credentials and immediately informs EviCore of any adverse actions relating to medical licenses and/or board certifications
Support and communicates eviCore policies and procedures to the provider community.
Participate in all required educational and quality improvement activities and maintain passing scores in all assessments
Other duties as assigned