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Medical Director for Complex Health Care
2 weeks ago
We partner with health plans and providers to deliver exceptional outcomes for individuals with complex health conditions.
As a Field Medical Director, you will be part of our utilization management team. You will have the opportunity to make a meaningful difference in patients' lives in a non-clinical environment, enjoying better work-life balance while collaborating with a talented team that values continuous learning and collaboration.
Your Responsibilities:
- Serve as the physician match reviewer for imaging cases that do not initially meet medical necessity guidelines and other specialty reviews.
- Discuss determinations with requesting physicians or ordering providers through peer-to-peer phone calls within regulatory timeframes, providing clinical rationale for standard and expedited appeals.
- Apply medical/clinical review guidelines and parameters to ensure consistency in the MD review process, reflecting appropriate utilization and compliance with SBU policies/procedures, URAC, and NCQA guidelines.
- Aid and act as a resource to Initial Clinical Reviewers.
- Ensure timely and accurate documentation of all communications with medical office staff and/or MD providers.
- Assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines, and system support.
- Participate in ongoing training per inter-rater reliability process.
Qualifications:
- MD/DO/MBBS degree
- Minimum 5 years of post-residency experience in active clinical practice within the last 2 years (preferred)
- Current, unrestricted clinical license in medicine or required specialty
- Obtaining and maintaining medical licenses in your state, as well as any license required per business needs
- Active Board Certification as an Otolaryngologist
- Strong clinical, management, communication, and organizational skills
- Energetic and curious with a passion for quality and value in healthcare
- No history of major disciplinary or legal action by a state medical board