Field Medical Director, Cardiology

What You’ll Be Doing Serve as the specialty match reviewer in Cardiology cases, that do not initially meet the applicable medical necessity guidelines, as well as other requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert. Provide clinical rationale for standard and expedited appeals. Discuss determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request. Utilize medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU’s policies/procedures, as well as URAC and NCQA guidelines. Ensure documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner. Participate in ongoing training per inter-rater reliability process. May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support. On a requested basis, may function as Medical Director for selecting health plans or regions, assuming overall accountability for utilization management while working in conjunction with the Senior Medical Director. Qualifications - Required and Preferred MD/DO/MBBS Degree Current, unrestricted clinical license in medicine or required specialty Obtaining and maintaining medical licenses in the state you reside, as well as, other state licensure required per business needs Active Board Certification in Cardiology, Vascular Surgery or Adult Congenital Heart Disease Strong clinical, management, communication, and organizational skills Energetic and curious with a passion for quality and value in health care Computer Proficiency Minimum of five (5) years’ experience in the practice of Cardiology is preferred Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an “excluded person” by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare. No history of a major disciplinary or legal action by a state medical board To comply with HIPAA security standards (45 C.F.R. sec. 164.308 (a) (3)), identity verification may be required as part of the application process. This is collected for compliance and security purposes and only reviewed if an applicant advances to the final interview state. Reasonable accommodations are available upon request. Technical Requirements: We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations. Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status. If you need reasonable accommodation to access the information provided on this website, please contact View email address on click.appcast.io for further assistance. The expected base salary/wage range for this position is $120-$135/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts. #J-18808-Ljbffr