Medical Principal

Implements policies and standards, evaluate new treatments, and conduct medical research to ensure the quality of the medical care provided to patients.

Implements utilization and financial initiatives.

Develops and manages efforts to improve and maintain cost and utilization trends.

Requires an MD or DO.

SUMMARY: The Medical Principal performs medical necessity review and case management activities.

The physician provides clinical insight to the organization through peer review, benefit review, peer to peer conversations, consultation, and service to internal and external customers.

RESPONSIBILITIES:

- Performs benefit-driven medical necessity reviews for coverage, case management, and claims resolution, using benefit plan information, applicable federal and state regulations, clinical guidelines, and best practice principles.

- Works to achieve quality outcomes for customers/members with a focus on service and cost

- Improves clinical outcomes through daily interactions with health care professionals using active listening, education, and excellent communication and negotiation skills.

- Balances customer/member needs with business needs while serving as a customer/member advocate at all times.

- Participates in all levels of the Appeal process as appropriate.

- Participates in coverage guideline development, development, and maintenance of medical management projects, and committees.

- Participates in quality processes such as audits, inter-rater reliability clinical reviews, and quality projects.

- Serves as a mentor or coach to other Medical Directors and other colleagues in quality and performance improvement processes.

- Improves health care professional relations through direct communication, knowledge of appropriate evidence-based clinical information, and the fostering of positive collegial relationships.

- Addresses customer service issues with mentoring and support from leadership staff.

- Investigates and responds to client and/or regulatory questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff.

- Achieves internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions.

- Provides clinical insight and management support to other functional areas and matrix partners as needed or directed.

Qualifications:

Required - Current unrestricted medical license in US state or territory.

- Current board certification in an ABMS or AOA recognized specialty (grandfathered by the board or maintained by the MOC program).

- Certification in a primary care specialty

- Exhibits ethical and professional behavior.

- Minimum of 5 years of clinical practice experience and/or direct patient care beyond residency.

- Computer Competency: Word processing, Spreadsheet, Email, and Personal Information Management programs are used extensively and compete...