Medical Director
4 weeks ago
The Medical Director - Radiology Specialist will be responsible for processing UM requests that do not meet guidelines, processing appeals, and education of the ordering providers in peer-to-peer calls. This role will also involve review of criteria yearly. The ideal candidate will have a NY, NM, or CA medical license and be a Board-Certified Radiologist.
Key Responsibilities:
- Process UM requests, appeals, and reconsiderations, writing denial rationales in compliance with health plans and government agencies.
- Ensure compliance with contractual obligations to health plans and government agencies, and certifications maintained by Care to Care.
- Participate in quarterly UM meetings.
- Identify educational needs and participate in ongoing education and support for medical and intake staff.
- Act as a clinical liaison to providers, clients, and patients as directed by the Chief Medical Officer.
- Communicate the need for additional clinical information to referring/prescribing providers related to consideration for authorization or modification of a referring provider's request for radiological or diagnostic imaging services.
- Collaborate with management to create and implement new processes or quality improvement initiatives.
- Coordinate with UM Intake Specialists to ensure timely and accurate communication of clinical decisions.
- Collaborate with the clinical team to review and update clinical criteria guidelines at least annually.
Required Certifications/Licensing:
- Current, unrestricted medical license in the required specialty (NY, NM, or CA license required).
- Board certified in Radiology required.
Preferred Qualifications:
- Strong clinical, management, and organizational skills.
- Excellent verbal and written communication skills.
- Proficient computer skills.
- High degree of personal integrity and ethical conduct.
- Self-motivated and directed.
- Works well with others.
Additional Job Requirements:
- Remain in a stationary position for prolonged periods.
- Be adaptive and change priorities quickly; meet deadlines.
- Attention to detail.
- Operate computer programs and software.
- Ability to communicate effectively with audiences in person and in electronic formats.
- Day-to-day contact with others (co-workers and/or the public).
- Making independent decisions.
- Ability to work in a collaborative business environment in close quarters with peers and varying interruptions.
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