Encore Medical Director - Express Scripts

The Cigna Group

3d • Remote

About The Position

A Medical Principal performs medical review and case management activities. The physician provides clinical insight to the organization through peer review, benefit review, consultation, and service to internal and external customers. He/she will serve as a clinical educator and consultant to utilization management, case management, network, contracting, pharmacy, and service operations (claims). This is an entry to mid-level position for a physician interested in a career in health care administration.

Requirements

• Current unrestricted medical license in a US state or territory.
• Current board certification (lifetime certification or certification maintained by MOC or other applicable program) in an ABMS or AOA recognized specialty
• Exhibits 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, PowerPoint and Personal Information Management programs are used extensively and competency in all must be possessed or rapidly acquired.
• Must not be excluded from participation in any federal health care program
• Must not be included in CMS’ Preclusion List

Nice To Haves

• 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.
• Fluency in Spanish or other languages

Responsibilities

• Performs benefit-driven medical necessity reviews for coverage, case management, and claims resolution, using benefit plan information, applicable federal and state regulations, clinical guidelines, and best practice principles.
• Works to achieve quality outcomes for customers/members with a focus on service and cost
• Improves clinical outcomes through daily interactions with health care professionals using active listening, education, and excellent communication and negotiation skills.
• Balances customer/member needs with business needs while serving as a customer/member advocate at all times.
• Participates in all levels of the Appeal process as appropriate and allowed by applicable regulatory agencies and accreditation organizations
• Participates in coverage guideline development, development and maintenance of medical management projects, initiatives and committees.
• Participates in quality processes such as audits, inter-rater reliability clinical reviews, and quality projects
• Serves as a mentor or coach to other Medical Directors and other colleagues in quality and performance improvement processes.
• Improves health care professional relations through direct communication, knowledge of appropriate evidence-based clinical information and the fostering of positive collegial relationships.
• Demonstrates knowledge as a peer reviewer by applying current evidence-based guidelines, including novel treatments, to support high-quality clinical decision-making across medical and behavioral health conditions, diseases, treatments, and procedures. Medical directors are required to maintain and update their knowledge base through monthly focused updates of Cigna's comprehensive evidence-based coverage policies, as well as through mandatory inter-rater reliability testing, continuing medical education, and maintenance of board certification.
• Addresses customer service issues with mentoring and support from leadership staff.
• Investigates and responds to client and/or regulatory questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff.
• Achieves 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.
• Provides clinical insight and management support to other functional areas and matrix partners as needed or directed.

Benefits

• If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

What This Job Offers

• Career Level: Entry Level