Medical Director

CAI•,

6d•$160 - $170•Remote

About The Position

We are looking for a motivated Medical Director ready to take us to the next level! If you have experience in utilization management, apply now. We are looking for a Medical Director to ensure utilization management responsibilities are performed in accordance with the highest and most current clinical standards. This position will be Full-Time and Remote.

Requirements

Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
Awarded Board Certification at least once in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
Active medical state licensure required for PA, NY, or WV
5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
Strong skills in Critical Thinking, Case Management, Customer Service, Oral & Written Communication, Collaboration, Listening, Telephone Skills, General Computer Skills, Clinical Software, and Managed Care

Nice To Haves

Master's Degree in Business Administration/Management or Public Health
1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry
Experience with MCG or InterQual

Responsibilities

Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer-to-peer discussions, to determine medical necessity and appropriateness
Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned
Compose clear and concise rationales for members and provider determination notifications while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.)
Ensure that all aspects of the medical management process are consistent with community standards of care
Participate as a member of the CMDM multidisciplinary team: attend huddles and grand rounds, and advise the multidisciplinary team on cases requiring physician expertise
Participate in protocol and guidelines development to ensure consistency in the review process
Actively manage projects and/or participate on project teams that require a physician subject matter expert