Medical Director - Neurology

Neurologist

Summary description of position : A Medical Principal performs medical/pharmacy reviews and case management activities.

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

He/she will serve as a clinical educator and consultant to utilization management, case management, network, contracting, pharmacy, and service operations (claims).

This is an entry to mid-level position for a physician interested in a career in health care administration.

Major responsibilities and required results:


* 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 and allowed by applicable regulatory agencies and accreditation organizations


* Participates in coverage guideline development, development and maintenance of medical management projects, initiatives 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.

Minimum Requirements:


* Current unrestricted license to practice medicine within the scope of his or her profession in a US state, territory, Commonwealth of the US or the District of Columbia


* Current board certification (lifetime certification or certification maintained by MOC or other applicable program) in an ABMS or AOA recognized specialty


* Exhibits ethical and professional behavior.
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