Medical Director – Clinical Ops Case Review - NEX

Medica•,

6d•$235,600 - $403,900•Remote

About The Position

The Medical Director – Clinical Operations has the responsibilities of supporting care management, quality, utilization management, credentialing, pharmacy, health policy implementation, technology assessment and risk management activities. This position requires a solid medical and business mind, with strong judgment and investigative nature, and an ability to develop medical policy that effectively balances provider, patient, and health plan interests. This person also works to bring consistency to all aspects of the decision-making surrounding the above noted activities. Performs other duties as assigned.

Requirements

Medical Doctorate (MD) or Doctor of Osteopathic Medicine (DO)
10+ years of experience beyond degree
5+ years of leadership experience
Must be a licensed physician with current Board certification of ABMS recognized specialty
Current medical license to practice must be without restrictions
Must be willing and able to successfully apply for medical license in other states as needed
Primary home address located within any state where Medica is registered as an employer - AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI
Legally authorized to work in the United States at the time of application.

Nice To Haves

Demonstrated proficiency in pre-service review, concurrent review, post-service review, case management and appeals (excellent case investigation skills)
Knowledge of pharmacy and therapeutics process, including prior experience in formulary development and utilization review is very desirable
Outstanding written, verbal and communications skills
Strong collaboration skills
Technical aptitude
Ability to represent Clinical on various Medica Committees
Strong process management skills
Strong ability to utilize various application technology systems
Excellent leadership skills
Customer service orientation - must enjoy speaking to network physicians
Actively influences and drives discussions toward resolution - shows good judgment and decisiveness

Responsibilities

Completes care management case review for cases involving medical necessity review, including standard and expedited pre-service, concurrent and post-service decisions, based on, but not limited to, Medica's technology policies/guidelines, member/enrollees COC/SPD and clinical knowledge expertise, as appropriate
Completes appeal case review for cases involving medical necessity review, including standard and expedited pre-service, concurrent and post-service decisions, based on, but not limited to, Medica's technology policies/guidelines, member/enrollee's COC/SPD and clinical knowledge expertise, as appropriate
Participates in rotation to above referenced decisions, and Clinical Grand Rounds with nurses.
Participates in review of coding appeal
Participates as needed in facility claims audit
Conducts review of the denial of ER services
Partners to establish priorities as appropriate for improving service at the point of care
Participates in case review inter-rater reliability process, as appropriate
Assists with review of data on utilization to identify potential over-, under- and mis-utilization of care
Assists with identifying interventions based on the information above
Participates in quality-of-care complaint inter-rater reliability process, as appropriate
Participates in on-call weekend/holiday coverage for Medicare Part D and expedited reviews
Serves as a reviewer on Clinical Appeals cases
Provides support to Medica’s case management programs
Completes quality of care complaint reviews for cases involving clinical aspects or clinical/service aspects
Participates in rotation to above
Participates in the technology assessment and benefit determination processes, as required
Chairs Medica’s Technology Assessment Committee and/or may be asked to participate in Committees as required
Serves as clinical representation to Medica’s Benefit Implementation Committee
Prior Authorization Work Group