Medical Director Jobs

About The Position

Requirements

• Minimum (3) years' nursing experience in clinical setting.
• Minimum (1) year experience UM experience with pre-service.
• Minimum (1) year experience with managed care (Medicaid and / or Medicare).
• Minimum 1 year of experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)
• Minimum (1) year experience in a medical setting working with IPAs, entering referrals / prior authorizations preferred.
• Minimum (1) Experience with the application of clinical criteria, specifically Milliman Care Guidelines (MCG).
• High School Diploma or GED.
• Must have and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact).
• Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company.
• Knowledge of ICD-10, CPT codes, managed care plans, medical terminology and referral system (Access Express / Portal / N-coder).
• Knowledgeable with CMS (Chapter 13) guidelines and regulations.
• Word, Excel, Microsoft Outlook.
• Effective written and verbal communication skills; able to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
• Able to perform mathematical calculations and calculate simple statistics correctly.
• Able to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Comprehend and analyze statistical reports.

Nice To Haves

• Associates or Bachelor's degree in Nursing.
• CPHQ or ABQAURP, or Six Sigma certification.
• Medical Terminology Certificate.
• Medical Terminology.
• Six Sigma.
• Bilingual English and Spanish.
• Transplant knowledge a plus.

Responsibilities

• Review pre-certification requests for medical necessity and refer to medical director any referral that requires additional expertise.
• Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilize Milliman Care Guidelines (MCG) to assist in determinations of referrals.
• Maintain goals for established turn-around time (TAT) for referral processing.
• Initiate single service agreements (SSA) when services required are not available in network.
• Maintain a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as efficiently as possible.
• Verify eligibility and / or benefit coverage for requested services.
• Verify accuracy of ICD 10 and CPT coding in processing pre-certification requests.
• Contact requesting provider and request medical records, orders, and / or necessary documentation in order to process related pre-service requests / authorizations when necessary.
• Review referral denials for appropriate guidelines and language.
• Assist medical directors in reviewing and responding to appeals and Grievances.
• Contact members and maintain documentation of call for expedited requests.
• Other duties as assigned.

Benefits

• Reimbursed licensure costs for Nevada, Arizona, North Carolina, and Texas.