Medical Director - Post-Acute Care - Evicore - Remote

Overview

Medical Director - Post-Acute Care - Evicore - Remote

Responsibilities

• 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; discuss 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 collection and review 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.
• Other duties as assigned.

Minimum Education, Licensure and Professional Certification

• MD or DO with active board certification in primary care specialties (Family Medicine, Internal Medicine or Emergency Medicine) OR board certification in Physical Medicine and Rehabilitation (American Board of Medical Specialties or American Osteopathic Association).
• Three or more years of relevant clinical practice post residency/fellowship.
• Active unrestricted license to practice medicine in a state or territory of the United States as a utilization review Doctor of Medicine or Doctor of Osteopathic Medicine.
• Knowledge of applicable state and federal laws, URAC and NCQA standards, and utilization management.
• Ability to commit to a set, weekly work schedule (Monday through Friday).
• Strong computer skills: ability to work autonomously with automated processes, computer applications, and systems.
• Meet physical demands of the role including typing, speaking, and listening 100% of the time.
• In accordance with HITECH Security Accreditation, company-provided encrypted workstation is required to be hard-wired connected to a modem or router. Wireless connection is not permitted.

Additional Details

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10 Mbps download/5 Mbps upload.

Salary: USD 203,200 - 338,600 per year, depending on experience and geographic location. This role is eligible to participate in an annual bonus plan.

Benefits include medical, vision, dental, well-being and behavioral health programs, 401(k) with company match, company-paid life insurance, tuition reimbursement, and at least 18 days of paid time off per year plus paid holidays. For more details visit Life at Cigna Group.

About Evernorth Health Services

Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you require reasonable accommodation in completing the online application process, please email: View email address on us.fitly.work for support. The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.