Medical Director
3 weeks ago
Job Description
Medical Director
Temp contract 20-25 hrs/wkly Remote
An actively practicing physician reviewer/advisor who holds a current, unrestricted license to practice medicine, has professional post-residency experience in direct patient care at some point in time during his professional career, provides direct support to utilization management activities, is oriented in the principles and procedures of utilization management, the URAC UM standards, and peer review, is qualified to render a clinical opinion about the medical condition, procedures, and treatment under review and is subject to the same credentialing/re-credentialing requirements as the rest of the clinical peer staff.
PURPOSE:
To ensure that physician utilization review staff are properly qualified, trained, supervised, and supported by explicit written clinical review criteria and review procedures and to ensure that they are qualified to review requests for services to determine the medical necessity and appropriateness of a treatment, medical procedure, hospital admission and/or continued stay, in all cases.
PROCEDURES:
- LHCM shall create a job description consistent with URAC Standards to which the Medical Director shall be held accountable.
- The Medical Director shall be bound by contract (see attached) to oversee the clinical peer review staff and may be used for second level reviews.
- The Medical Director shall be subject to the direction and control of the Executive Director of LHCM on business-related issues and subject to the policies and procedures of LHCM, the URAC UM standards, all material aspects of applicable laws and regulations governing licensing and conduct of physicians, and the standards of practice for his clinical specialty on all other issues.
Duties of the Medical Director
- Formal and informal case or utilization review of active claims consistent with URAC standards.
- Assist in the review of large case management files.
- Assist LHCM in complying with URAC standards.
- Serve as a medical resource and advisor based on accepted national guidelines on behalf of LHCM and its clients regarding medical necessity, quality improvement and utilization in a manner that is consistent with URAC standards.
- Participate in educational, marketing or customer service activities as requested by the Director of Clinical Services.
- Serve as a representative of LHCM as requested by the Director of Clinical Services.
- As requested by and with the Director of Clinical Services, participate in the growth, development and improvement of services and products delivered to current or potential LHCM.
- Participate in the continuous quality improvement efforts of LHCM in a manner that is consistent with URAC standards.
- Assist the Director of Administration, Supervisor of Utilization Review, Supervisor of Case and Disease Management as requested by the Director of Clinical Services.
- Assist in the review and development of Disease Management and Demand Management programs for clients served by LHCM.
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