Medical Director-Dermatology Appeals

CareBridge-posted 3 months ago
Full-time • Senior
Metairie, LA
251-500 employees
Ambulatory Health Care Services
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The Medical Director-Dermatology Appeals is responsible for the review of appeals for physical health medical services, to ensure the appropriate and most cost-effective medical care is received. May be responsible for developing and implementing programs to improve quality, cost, and outcomes. May provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations. May identify cost of care opportunities. May serve as a resource to staff including Medical Director Associates. May be responsible for an entire clinical program.

  • Complete appeal reviews in your specialty daily to ensure timely and consistent responses to members and providers.
  • Provide guidance for clinical operational aspects of a program.
  • Conduct peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations.
  • Serve as a resource and consultant to other areas of the company.
  • Represent the company to external entities and/or serve on internal and/or external committees.
  • Chair company committees.
  • Interpret medical policies and clinical guidelines.
  • Lead, develop, direct, and implement clinical and non-clinical activities that impact health care quality cost and outcomes.
  • Identify and develop opportunities for innovation to increase effectiveness and quality.
  • Work independently with oversight from immediate manager.
  • Be responsible for an entire clinical program and/or independently perform clinical reviews.
  • Requires MD or DO and Board certification approved by one of the following certifying boards: American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
  • Board certification in Dermatology.
  • Must possess an active unrestricted medical license to practice medicine or a health profession.
  • Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
  • For Health Solutions and Carelon organizations, minimum of 5 years of experience providing health care is required.
  • Additional experience may be required by State contracts or regulations if the Medical Director is filling a role required by a State agency.
  • Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
  • Merit increases
  • Paid holidays
  • Paid Time Off
  • Incentive bonus programs
  • Medical, dental, vision benefits
  • Short and long term disability benefits
  • 401(k) + match
  • Stock purchase plan
  • Life insurance
  • Wellness programs
  • Financial education resources
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