Medical Director, Prior Authorization

CorroHealth•WA-Remote, WA

6d•Remote

About The Position

Seeking a highly skilled and detail oriented Medical Director to join our team. The Medical Director will play a critical role in assessing the quality of clinical services provided to Medicare beneficiaries ensuring compliance with clinical guidelines and regulations while helping to drive improvements in care delivery. After completion of mentored training, daily work includes reviewing and analyzing clinical records, charts and case files to ensure that all clinical practices, treatments and services provided to Medicare beneficiaries meet the highest standards of care and adhere to CMS regulations, policies and procedures. The ideal candidate works closely with multidisciplinary teams to provide insights and feedback on clinical cases and improvement opportunities. This is a remote position.

Requirements

Be a board-certified clinician, including a Doctor of Medicine or a Doctor of Osteopathy identified by an individual NPI in a specialty recognized by the American Board of Medical Specialties Anesthesiologists or those with a completed fellowship in pain management are strongly preferred OR be associated with a primary specialty designation that aligns with PMR, neurology, pulmonology, urology, or orthopedics.
Board certified for at least 3 years;
Currently hold an active, valid and unrestricted license to practice medicine in at least one U.S. state, territory, or the District of Columbia.
Must not be excluded from participating in Medicare, Medicaid or the Children’s Health Insurance Program.
Excellent communication skills (both verbal and written) with the ability to collaborate effectively with diverse healthcare teams.
Familiarity with electronic health records (EHR) and documentation and coding practices (ICD-10, CPT)
Knowledge of CMS regulations and Medicare requirements.
Strong attention to detail and organizational skills to manage multiple tasks and priorities
Ability to work in a fast paced, deadline driven environment

Nice To Haves

State of Washington license to practice medicine preferred or willingness to obtain.
Utilization management experience preferred.

Responsibilities

Conduct regular reviews to monitor the appropriateness of care provided to beneficiaries and recommend any necessary interventions or adjustments need to align with CMS National and Local Coverage Determinations (NCD/LCD)
Prepare for and participate in peer-to-peer discussions with providers and suppliers to review clinical documentation, discuss coverage criteria, and address questions related to prior authorization requests.
Assist in the training and development of clinical teams on CMS NCD/LCD guidelines, clinical documentation and compliance.
Provide recommendations for improvements in clinical practices based on findings from record reviews, data analysis, and best practices in the field.
Participate in the development and implementation of quality improvement initiatives to enhance care delivery and achieve CMS performance goals.
Maintain accurate and up to date records of all clinical reviews, audits and quality improvement efforts.