Medical Director

Cigna Healthcare•California Work at Home, CA

23h•$230,600 - $384,400•Remote

About The Position

The job profile for this position is Medical Director, which is a Band 5 Management Career Track Role. We value our talented employees, and whenever possible strive to help one of our associates grow professionally before recruiting new talent to our open positions. If you think the open position you see is right for you, we encourage you to apply! Our people make all the difference in our success. Medical Director: Inpatient Utilization and Population Management ABOUT OUR TEAM: We pride ourselves on being trusted clinical leaders and subject matter experts in the market and across the enterprise. Our customers and patients are at the center of all we do as we partner with providers, customers, and internal colleagues to drive toward the best clinical outcomes Are you ready to make an impact? POSITION SUMMARY: As an Inpatient Medical Director, you’ll provide critical clinical insight across the enterprise supporting the effectuation of MCG guidelines for level of care appropriateness You’ll have the opportunity to partner with leaders across all business units including Express Scripts and Evernorth to develop solutions to some of the greatest challenges in health care. As a manager of direct reports, a growth mindset and desire to lead are paramount.

Requirements

Current unrestricted medical license in a US state or territory
Current board certification in an ABMS or AOA recognized specialty (grandfathered by the board or maintained by the MOC program)
Ethical and professional behavior
Minimum of 5 years of clinical practice experience and/or direct patient care beyond residency
Computer Competency: Word processing, Spreadsheet, Email, and Personal Information Management programs are used extensively and competency in all must be possessed or rapidly acquired. Must be able to research clinical issues on internet resources
Ability to travel to attend meetings in person as needed

Nice To Haves

At least three years’ experience in medical management, utilization review and case management in a managed care setting
Knowledge of Pharmacy Claims and utilization management is a plus
Knowledge of Specialty Pharmaceuticals and management is a plus
Previous experience managing physicians, nurses or employees is a plus but not required
Experience in medical management, utilization review and case management in a managed care setting
Knowledge of managed care products and strategies
Ability to work within changing business environment and balance patient advocacy with business needs
Experience with managing multiple projects in a fast-paced matrix environment
Demonstrated ability to educate colleagues and staff members
Successful experience and comfort with change management
Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem solving skills
Successful ability to assess complex issues, to determine and implement solutions, and resolve problems
Success in creating and maintaining cooperative, successful relations with diverse internal and external stakeholders
Demonstrated sensitivity to culturally diverse situations, participants, and customers/members
Service marketing, sales, and business acumen experience a plus

Responsibilities

Lead a team of clinicians to deliver superior results for organization by supporting utilization management functions as well strategic clinical initiatives
Perform benefit-driven medical necessity reviews for coverage, case management, and claims resolution as needed using benefit plan information, applicable federal and state regulations, clinical guidelines, and best practice principles
Work to achieve quality outcomes for customers with a focus on service and cost
Improve clinical outcomes through daily interactions with health care professionals using active listening, education, and excellent communication and negotiation skills
Balance customer/member needs with business needs while serving as a customer advocate at all times
Participate in all levels of the Appeal process as appropriate
Participate in coverage guideline development, development, and maintenance of medical management projects, and quality committees
Participate in quality processes such as reviews, inter-rater reliability clinical reviews, and quality projects
Serve as a mentor or coach to other Medical Directors and other colleagues in quality and performance improvement processes.
Improve health care professional relations through direct communication, knowledge of appropriate evidence-based clinical information, and the fostering of positive collegial relationships
Address customer service issues with mentoring and support from leadership staff
Investigate and respond to client and/or regulatory questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff
Achieve internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions
Provide clinical insight and management support to other functional areas and matrix partners as needed or directed
Direct the medical management functions for a market, region, or national programs including overseeing utilization review and quality assurance, directing case management, developing medical policies and evaluating new technologies and treatments
Operate as a senior clinician for a market, region or nationally where required
Create and implement medical management strategic plans for a market, region or nationally
Support network operations and act as physician liaison in community
Investigate and respond to client questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff
Achieve customer satisfaction by assuring both timely turn-around of coverage reviews and quality outcomes