Medical Director – Clinical Ops Case Review - NEX

Key Accountabilities

• Care Management and Appeals Decisions
• Completes care management case review for cases involving medical necessity review, including standard and expedited pre-service, concurrent and post-service decisions, based on, but not limited to, Medica's technology policies/guidelines, member/enrollees COC/SPD and clinical knowledge expertise, as appropriate
• Completes appeal case review for cases involving medical necessity review, including standard and expedited pre-service, concurrent and post-service decisions, based on, but not limited to, Medica's technology policies/guidelines, member/enrollee's COC/SPD and clinical knowledge expertise, as appropriate
• Participates in rotation to above referenced decisions, and Clinical Grand Rounds with nurses
• Participates in review of coding appeal
• Conducts review of the denial of ER services
• Serves as a reviewer on Clinical Appeals cases
• Provides support to Medica’s case management programs
• Quality of Care Complaints Participation
• Completes quality of care complaint reviews for cases involving clinical aspects or clinical/service aspects
• Quality of Care Complaints Participation
• Participates in quality-of-care complaint inter-rater reliability process, as appropriate
• Quality of Care Complaints Participation
• Serves as clinical representation to Medica’s Benefit Implementation Committee

Qualifications

• Medical Doctorate (MD) or Doctor of Osteopathic Medicine (DO)
• 10+ years of experience beyond degree
• 5+ years of leadership experience

Required Certifications/Licensure

• Must be a licensed physician with current Board certification of ABMS recognized specialty
• Current medical license to practice must be without restrictions
• Must be willing and able to successfully apply for medical license in other states as needed

Preferred Qualifications

• Demonstrated proficiency in pre-service review, concurrent review, post-service review, case management and appeals (excellent case investigation skills)
• Knowledge of pharmacy and therapeutics process, including prior experience in formulary development and utilization review is very desirable
• Outstanding written, verbal and communications skills
• Strong collaboration skills
• Technical aptitude
• Ability to represent Clinical on various Medica Committees
• Strong process management skills
• Strong ability to utilize various application technology systems
• Excellent leadership skills
• Customer service orientation - must enjoy speaking to network physicians
• Actively influences and drives discussions toward resolution - shows good judgment and decisiveness