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Medical Director for Complex Health Care

2 weeks ago


Nashville, Tennessee, United States Evolent Full time
Evolent Field Medical Director-ENT Opportunity

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:

  1. Serve as the physician match reviewer for imaging cases that do not initially meet medical necessity guidelines and other specialty reviews.
  2. 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.
  3. 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.
  4. Aid and act as a resource to Initial Clinical Reviewers.
  5. Ensure timely and accurate documentation of all communications with medical office staff and/or MD providers.
  6. Assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines, and system support.
  7. 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