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Medical Director/Center Physician
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Medical Director/Center Physician
2 weeks ago
Providence, Rhode Island, United States CSL Plasma Full timeJob SummaryCSL Plasma is seeking a highly skilled Medical Director/Center Physician to join our team. As a Medical Director/Center Physician, you will be responsible for providing medical oversight and ensuring compliance with applicable Federal and State regulations. You will also be responsible for monitoring medical compliance, reviewing and signing...
Nurse Medical Director
2 months ago
Absolute Staffing & Consulting Solutions is seeking a highly skilled Nurse Medical Management professional to join our team. As a key member of our healthcare management team, you will play a critical role in promoting quality member outcomes, optimizing member benefits, and ensuring effective use of resources for complex medical issues.
Key Responsibilities- Collaboration and Communication: Collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and ensure effective use of resources for complex medical issues.
- Medical Necessity Assessment: Assess the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out-of-network services, and appropriateness of treatment setting by utilizing applicable medical policy and industry standards.
- Care Coordination: Conduct precertification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
- Consultation and Collaboration: Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
- Member Care Transition: Facilitate member care transition through the healthcare continuum and refer treatment plans/plan of care to clinical reviewers as required.
- Accreditation and Compliance: Facilitate accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
- Education and Experience: Current active unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States. Minimum of 3 years acute care clinical experience or case management, utilization management, or managed care experience.
- Preferred Qualifications: Participation in the American Association of Managed Care Nurses. Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
