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

Summary:

The Medical Director 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.

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Responsibilities include:


* Provide timely expert medical review of medical necessity requests for clinical services related to 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.


* Participate in proactive peer to peers to assist with appropriate and timely discharge planning.


* 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 eviCore of any adverse actions relating to medical licenses and/or board certifications.


* Support the review of eviCore clinical guidelines.


* Support and communicate eviCore 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 eviCore 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 (JOC) meetings, including the review and collection of data relevant to the client, and other virtual events with the provider engagement team in your specified territory.


* 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


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

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 in Physical Medicine and Rehabilitation


* Active unrestricted license to practice medicine in a state or territory of the United States as a ut...