Medical Director - Post Acute Care - Evernorth Home-based Care

Medical Director, Post-Acute Care

Summary:

The Medical Director (MD) provides timely expert medical review of medical necessity requests for clinical services that do not meet utilization review criteria and renders a clinical opinion about the medical service under review while located in a state or territory of the United States.

Responsibilities include:


* Provide timely expert medical review of medical necessity requests for clinical services (including post-acute care) and render a clinical opinion about the medical service under review, including post-decision reviews.


* Provide timely and collegial peer-to-peer discussions with treating physicians to clarify clinical information and to explain review outcome decisions.


* Document all actions related to clinical review sessions and attest to review qualifications as required.


* Conduct weekly Case Conferences with nursing and social worker teams; discussing every assigned member receiving care in a post-acute care facility, focusing on discharge planning, complex medical care management, quality of care, appropriate level of care, and appropriate length of stay.


* Maintain necessary credentials and immediately inform the Company of any adverse actions relating to medical licenses and/or board certifications.


* Support the review of clinical guidelines.


* Support and communicate company policies and procedures to the provider community.


* Testify at ALJ Hearings when your cases are being appealed


* Assist with staff educational training and in-service programs and serve as a clinical resource for staff.


* Serve as a Subject Matter Expert when Medical Directors and/or Senior Medical Directors are unavailable.


* Available for scheduled weekend call from home based on business needs.


* Participate in Joint Operating Committee meetings and other Virtual events with the Provider Engagement Team in your geographic territory.


* Review and document on cases that are appealed and work with the providers proactively to help with accurate case adjudication


* Participate in all required educational and quality improvement activities and maintain passing scores in all assessments.


* Assist in reviewing case determinations from clients responding to a provider or member complaint


* Other duties as assigned

Minimum Education, Licensure and Professional Certification requirement:


* M.D.

or D.O.

degree from accredited institution.


* Minimum of five (5) years of clinical practice experience after completion of all graduate medical education training, including residency and fellowship (when applicable)


* Active board certification, primary care specialties (Family Medicine, Internal Medicine, Emergency Medicine) or Physical Medicine and Rehabilitation required.


* Active unrestricted license to practice medicine in a state or territory of the United States as a utilization review doctor of medicine or doc...