Medical Director

Physician-CW - Medical Director-CW

100% Remote. Estimated full-time salary ranges from $225K-$300K.

Job Description: Medical Director Job Description Looking for: MD/DO with 5+ years clinical experience Board Certified (ABMS/AOA) Active PA, NY, or WV license Strong Payer-Side Utilization Management experience Medical Necessity Reviews, Appeals & Grievances Peer-to-Peer experience MCG/InterQual preferred

Responsibilities: Medical necessity reviews, escalated cases, Peer-to-Peer discussions, appeals/grievances, and clinical guideline support. This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service. Depending on the nature of the case, telephonic peer to peer discussions may be required. The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management. They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the incumbent may be assigned special projects to help support and improve the care of our members.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness.
• Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned.
• Compose clear and concise rationales for members and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.).
• Ensure that all aspects of the medical management process are consistent with community standards of care.
• Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise multidisciplinary team on cases that require physician expertise.
• Participate in protocol and guidelines development to ensure consistency in the review process.
• Actively manage projects and/or participate on project teams that require a physician subject matter expert.
• Other duties as assigned.

Required Qualifications

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
• 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
• Awarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
• Active medical state licensure required for PA, NY, or WV.
• Critical Thinking
• Case Management
• Customer Service
• Oral & Written Communication Skills
• Collaboration
• Listening
• Telephone Skills
• General Computer Skills
• Clinical Software
• Managed Care

Preferred Qualifications

• Master's Degree in Business Administration/Management or Public Health
• 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry
• Experience with MCG or InterQual

Additional Details

• Fully remote
• Must be a US citizen
• Contract with the possibility of full-time hire.
• Beeline for timesheets
• Must complete the Medical Director Assessment
• Hrs/Wk: 40
• Work schedule: 9am-5pm EST core hours. Flexible to time zones. Once properly trained, can adjust start time.
• The expectation is resources will be able to complete 55+ cases in an 8 hour day.
• They use two systems for reviews: Predictal and Beacon.
• Please categorize your candidates as either Behavioral Health or Non Behavioral Health (Physical Health) in the submit form.
• Manager's feedback: the candidates they've interviewed thus far have not had as much experience (if any) in the UM area from the payer side. Most have just had UM experience on the hospital side which unfortunately is not the same as doing it from the health insurance side.
• Individuals who have started as a Medical Director or those who accepted/accept offers may choose to obtain malpractice insurance. While this is not a requirement, some physicians prefer to secure coverage before practicing. Should you elect to do so, the cost of the insurance will be your personal responsibility and will not be reimbursed. There is no min required for malpractice insurance as it is not a requirement.

About Us: InterSources Inc

InterSources Inc, a Certified Diverse Supplier, was founded in 2007 and offers innovative solutions to help clients with Digital Transformations across various domains and industries. Our history spans over 19 years and today we are an Award-Winning Global Software Consultancy solving complex problems with technology. We recognize that our employees and our clients are our strengths as the diverse talents and opportunities they bring to the table enable us to grow as a global platform and they are causally linked with our success. We provide strategic and technical advice, and we have expertise in areas covering

Artificial Intelligence, Cloud Migration, Custom Software Development, Data Analytics Infrastructure & Cloud Solutions, Cyber Security Services, etc.

We make reasonable accommodations for clients and employees and we do not discriminate based on any protected attribute including race, religion, color, national origin, gender sexual orientation, gender identity, age, or marital status. We also are a Google Cloud partner company. We align strategy with execution and provide secure service solutions by developing and using the latest technologies that thrive our resources to deliver industry-leading capabilities to our clients and customers, making it convenient for our clients to do business with InterSources Inc. Our teams also drive growth by refining technology-driven client experiences that put the users first, providing an unparalleled experience. This results in strengthening the core technologies of clients, enabling them to scale with flexibility, create seamless digital experiences and build lifelong relationships.