UM Medical Director DME - Pacific or Mountain Time Zone preferred - Remote

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
• Participate in daily clinical rounds as requested
• 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
• Call coverage rotation

Required Qualifications

• M.D or D.O
• Active unrestricted license to practice medicine
• Board certification in Physical Medicine & Rehabilitation, Internal Medicine, Emergency or Family Medicine
• 3+ years of clinical practice experience after completing residency training
• Sound understanding of Evidence Based Medicine (EBM)
• Proven solid PC skills, specifically using MS Word, Outlook, and Excel

Preferred Qualifications

• Multiple State Licenses
• Experience in utilization and clinical coverage review
• Proven data analysis and interpretation aptitude
• Proven innovative problem-solving skills
• Proven excellent oral, written, and interpersonal communication skills, facilitation skills
• Proven excellent presentation skills for both clinical and non-clinical audiences
• Reside in Pacific or Mountain Time Zone

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution