SVP Medical Director

Sedgwick

7d • $250,000 - $275,000 • Hybrid

About The Position

The SVP Medical Director will evaluate medical reports escalated due to deficient information using evidence-based criteria. This role provides leadership within a dedicated team of clinicians and claims professionals, supporting the program through training and implementation of medical best practices. Additionally, the position offers client-facing support for Human Resources with ADAAA and FMLA, requiring medical expertise. The role adheres to service delivery timeframes, customer satisfaction, and overall workflow support. The ideal candidate thrives in a collaborative environment and is driven to deliver great work. This role involves client-facing clinical support, participating in client stewardship discussions, claim roundtables, and complex medical escalations. It also requires staying current on emerging medical trends, treatment standards, clinical literature, and evidence-based guidelines to support client conversations and operational decisions. Expertise in workers’ compensation, disability, FMLA, fitness-for-duty, return-to-work, liability, and safety-sensitive workforce issues is essential. The role may support operational needs for Utilization Review and Physician Advisor Support, care management strategy, vendor alignment, and quality improvement. Obtaining and maintaining Medical Director licensure in select states is also a requirement. The position applies clinical guidelines and medical literature to support defensible recommendations, claim discussions, treatment-plan clarification, and return-to-work/disability-related decision-making. It also involves engaging treating providers, supporting appeals, independent medical review considerations, peer review alignment, and clinical quality review.

Requirements

• Medical Doctor (M.D.) degree required.
• Ten (10) of related experience required
• one (1) to three (3) years utilization review experience
• three (3) years clinical quality control.
• 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 available regarding regulations and parameters of third party reimbursement, benefit determinations and payments
• Knowledge of statutory requirements of state's jurisdiction/ERISA regulations
• Knowledge about general claim practices.
• Excellent oral and written communication skills, including presentation skills
• PC literate, including Microsoft Office products
• Analytical and interpretive skills
• Strong organizational skills
• Excellent interpersonal skills
• Proven management/leadership skills
• Ability to create and complete comprehensive, accurate and constructive written reports
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies

Nice To Haves

• Knowledge of pharmacy processes and pharmacy benefit management a plus.
• Understanding of pain management a plus.

Responsibilities

• Conducting reviews on cases where the nurse is seeking treatment plan clarification, claim denial, disability certification or duration management for return to work guidance.
• Generating phone calls to treating physicians to enter into a motivational conversation to create an environment for positive discussion outlining the facts and evidence to make appropriate claim determinations.
• Documenting recommendations within templates in Juris and SharePoint using the appropriate format referencing evidence-based criteria within the required time frame.
• Oversight of the appeal and review process including making a recommendation of specialty for the Independent Medical Review process.
• Developing and delivering training materials and presentations to meet training needs.
• Interfacing and providing guidance and leadership to the Client dedicated leadership team as well as team leads where appropriate.
• Following established policy and procedures to assure compliance to best practices, service standards, state regulations, and client service requirements and assure efficient, cost effective, quality program delivery for medical and disability management.
• Coordinating and evaluating the service delivery between the company, partners, and vendors.
• Member of a client Disability Pension Board Review of identified appeal cases for quality assurance purposes.
• Voting member to determine if eligibility requirements have been met.
• Quarterly meeting attendance telephonically or virtually.
• Provides MRO expertise in special cases where a case is escalated.
• Provides assistance where occupational health expertise is needed.
• Collaborates with other parts of the company as needed.
• Performs other duties as assigned.
• Supports the organization's quality program(s).
• Travels as required.
• Provides support, guidance, leadership and motivation to promote maximum performance.
• Administers company personnel policies in all areas and follows company staffing standards and training recommendations.
• Interviews, hires and establishes colleague performance development plans; conducts colleague performance discussions.

Benefits

• Three medical, and two dental & vision plans to choose from.
• Tuition reimbursement
• 401K plan that matches 50% on every $ you put in up to the first 6% you save.
• 4 weeks PTO your first full year.
• Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
• Physical: Computer keyboarding.
• Auditory/Visual: Hearing, vision and talking
• Medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree