Medical Director - Clinical Ops Case Review - NEX

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for. We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued. The Medical Director – Clinical Operations has the responsibilities of supporting care management, quality, utilization management, credentialing, pharmacy, health policy implementation, technology assessment and risk management activities. This position requires a solid medical and business mind, with strong judgment and investigative nature, and an ability to develop medical policy that effectively balances provider, patient, and health plan interests. This person also works to bring consistency to all aspects of the decision-making surrounding the above noted activities. Performs other duties as assigned. *This is a part time role working 8 hours on Friday's Key Accountabilities

• Care Management and Appeals Decisions Participation
• Completes care management case review for cases involving medical necessity review, including standard and expedited pre-service, concurrent and post-service decisions, based on, but not limited to, Medica's technology policies/guidelines, member/enrollees COC/SPD and clinical knowledge expertise, as appropriate
• Completes appeal case review for cases involving medical necessity review, including standard and expedited pre-service, concurrent and post-service decisions, based on, but not limited to, Medica's technology policies/guidelines, member/enrollee's COC/SPD and clinical knowledge expertise, as appropriate
• Participates in rotation to above referenced decisions, and Clinical Grand Rounds with nurses.
• Participates in review of coding appeal
• Participates as needed in facility claims audit
• Conducts review of the denial of ER services
• Care Management Program and Initiatives Participation
• Partners to establish priorities as appropriate for improving service at the point of care
• Participates in case review inter-rater reliability process, as appropriate
• Assists with review of data on utilization to identify potential over-, under- and mis-utilization of care
• Assists with identifying interventions based on the information above
• Participates in quality-of-care complaint inter-rater reliability process, as appropriate
• Participates in on-call weekend/holiday coverage for Medicare Part D and expedited reviews
• Serves as a reviewer on Clinical Appeals cases
• Provides support to Medica’s case management programs
• Quality of Care Complaints Participation
• Completes quality of care complaint reviews for cases involving clinical aspects or clinical/service aspects
• Participates in rotation to above
• Committee Participation
• Participates in the technology assessment and benefit determination processes, as required
• Chairs Medica’s Technology Assessment Committee and/or may be asked to participate in Committees as required
• Serves as clinical representation to Medica’s Benefit Implementation Committee
• Prior Authorization Work Group

Required Qualifications

• Medical Doctorate (MD) or Doctor of Osteopathic Medicine (DO)
• 10+ years of experience beyond degree
• 5+ years of leadership experience

Required Certifications/Licensure

• Must be a licensed physician with current Board certification of ABMS recognized specialty
• Current medical license to practice must be without restrictions
• Must be willing and able to successfully apply for medical license in other states as needed

Preferred Qualifications * Demonstrated proficiency in pre-service review, concurrent review, post-service review, case management and appeals (excellent case investigation skills)

• Knowledge of pharmacy and therapeutics process, including prior experience in formulary development and utilization review is very desirable
• Outstanding written, verbal and communications skills
• Strong collaboration skills
• Technical aptitude
• Ability to represent Clinical on various Medica Committees
• Strong process management skills
• Strong ability to utilize various application technology systems
• Excellent leadership skills
• Customer service orientation - must enjoy speaking to network physicians
• Actively influences and drives discussions toward resolution - shows good judgment and decisiveness

This position is a Remote role. To be eligible for consideration, candidates must have a primary home address located within any state where Medica is registered as an employer - AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI The full salary grade for this position is $235,600 - $403,900. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $235,600 - $319,770. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data.  In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees. The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law. Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States. We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.