Medical Director, Occupational Health & Workers’ Compensation Managed Care

Sedgwick

29d•Hybrid

About The Position

The Medical Director evaluates medical reports escalated for deficient information and provides leadership to a dedicated team of clinical and claims professionals. The role supports the program through training and implementation of medical best practices, and provides client-facing medical expertise for services supporting Human Resources, including ADAAA and FMLA matters. The Medical Director is responsible for meeting service delivery time frames, customer satisfaction expectations, and workflow needs. The position applies evidence-based guidelines and medical literature to claim discussions, treatment-plan clarification, return-to-work and disability decisions, appeals, and clinical quality reviews. It supports workers’ compensation, disability, FMLA, fitness-for-duty, liability, and safety-sensitive workforce issues, as well as managed-care operations such as utilization review, physician advisor support, care management strategy, vendor alignment, and quality improvement. The role includes client partnership and stewardship, provider engagement, operational and team leadership, and travel of approximately 25%–30%. Medical Director licensure in selected states must be obtained and maintained as needed.

Requirements

Medical Doctor (M.D.) degree.
Ten years of related experience.
One to three years of utilization review experience.
Three years of clinical quality control experience.
Knowledge of evidence-based guidelines.
Knowledge of ADAA and FMLA.
Knowledge of utilization review procedures.
Knowledge of clinical quality systems and measurements.
Knowledge of resources concerning regulations and parameters of third-party reimbursement, benefit determinations, and payments.
Knowledge of statutory requirements in state jurisdictions and ERISA regulations.
Knowledge of general claim practices.
Excellent oral and written communication skills, including presentation skills.
PC literacy, including Microsoft Office products.
Analytical and interpretive skills.
Strong organizational skills.
Excellent interpersonal skills.
Proven management and leadership skills.
Ability to create comprehensive, accurate, and constructive written reports.
Ability to work in a team environment and meet or exceed Performance Competencies.
Ability to meet deadlines, handle multiple priorities, and manage work-related stress.
Ability to obtain and maintain Medical Director licensure in selected states as needed.

Nice To Haves

Experience with insurance carriers, third-party administrators (TPAs), or managed-care organizations.
Knowledge of pharmacy processes and pharmacy benefit management.
Understanding of pain management.

Responsibilities

Evaluate cases involving treatment-plan clarification, claim denial, disability certification or duration management, and return-to-work guidance.
Call treating physicians to discuss case facts and evidence and support appropriate claim determinations.
Document recommendations in Juris and SharePoint templates, referencing evidence-based criteria and meeting required time frames.
Oversee the appeal and review process, including recommending specialties for Independent Medical Review.
Develop and deliver training materials and presentations.
Provide guidance and leadership to client-dedicated leadership teams and team leads.
Follow policies and procedures to support best practices, service standards, state regulations, client requirements, and efficient, cost-effective, quality program delivery for medical and disability management.
Coordinate and evaluate service delivery among the company, partners, and vendors.
Serve on a client Disability Pension Board, review identified appeal cases for quality assurance, and vote on whether eligibility requirements are met.
Attend quarterly meetings by telephone or virtually.
Provide MRO expertise in escalated special cases and occupational health expertise when needed.
Collaborate with other parts of the company as needed.
Stay current on medical trends, treatment standards, clinical literature, and evidence-based guidelines, and support related client discussions and operational decisions.
Participate in client stewardship discussions, claim roundtables, and complex medical escalations.
Support workers’ compensation, disability, FMLA, fitness-for-duty, return-to-work, liability, and safety-sensitive workforce issues.
Support managed-care operational needs, including utilization review, physician advisor support, care management strategy, vendor alignment, and quality improvement.
Obtain and maintain Medical Director licensure in selected states as needed for regulatory, managed-care, utilization-review, and operational requirements.
Engage treating providers when needed and support appeals, independent medical review considerations, peer review alignment, and clinical quality review.
Support the organization’s quality programs and travel as required.
Provide support, guidance, leadership, and motivation to promote performance.
Administer company personnel policies and follow staffing standards and training recommendations.
Interview and hire colleagues, establish performance development plans, and conduct performance discussions.
Perform other duties as assigned.