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...
- Rate: Not Specified
- Location: Bloomfield, US-CT
- Type: Permanent
- Industry: Finance
- Recruiter: Cigna
- Contact: Recruiter Name
- Email: to view click here
- Reference: 24012777
- Posted: 2024-09-27 08:31:18 -
- View all Jobs from Cigna
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