Medical Director - Clinical Advocacy and Support - Remote - PST preferred

Primary Responsibilities

• Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies
• Render coverage determinations
• Document clinical review findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements
• Engage with requesting providers as needed in peer-to-peer discussions
• Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
• Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy
• Communicate and collaborate with other internal partners
• Participate in coverage rotation

Required Qualifications

• M.D. or D.O.
• Active unrestricted license to practice medicine
• Board certification in an ABMS specialty with Internal Medicine or Family Medicine preferred but other specialites can be considered
• 3+ years of clinical practice experience after completing residency training
• Demonstrated sound understanding of Evidence Based Medicine (EBM)
• Proven solid PC skills, specifically using MS Word, Outlook, and Excel

Preferred Qualifications

• CA, OR, WA or AZ licensure or willing to obtain
• Experience in utilization and clinical coverage review
• Proven excellent oral, written, and interpersonal communication skills, facilitation skills
• Proven data analysis and interpretation aptitude
• Proven innovative problem-solving skills
• Proven excellent presentation skills for both clinical and non-clinical audiences

Pay and Benefits

The salary for this role will range from $248,500 - $373,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Information

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.