Medical Director

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 all 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.
• Advise multidisciplinary team on cases that require 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.

Requirements

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
• 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
• Awarded Board Certification at least once in 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
• Critical Thinking
• Case Management
• Customer Service
• Oral & Written Communication Skills
• Collaboration
• Listening
• Telephone Skills
• General Computer Skills
• Clinical Software
• Managed Care

Preferred Qualifications

• 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