Medical Principal

Medical Principal Job Description

Position scope:

Primarily regional with national level case work for Cigna Healthcare (CHC) -- Cigna.

Summary description of position : A Medical Principal performs medical review 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.


* Demonstrates knowledge as a peer reviewer by applying current evidence-based guidelines, including novel treatments, to support high-quality clinical decision-making across medical and behavioral health conditions, diseases, treatments, and procedures.

Medical directors are required to maintain and update their knowledge base through monthly focused updates of Cigna's comprehensive evidence-based coverage policies, as well as through mandatory inter-rater reliability testing, continuing medical education, and maintenance of board certification.


* 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 ...