Medical Director

Medical Director

As the Medical Director, you will ensure utilization management responsibilities are performed in accordance with the highest and most current clinical standards. This position will be Full-Time and Remote.

What You'll Do:

• 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 while adhering to required compliance standards (NCQA, URAC, CMS, DOH, 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, and advise the multidisciplinary team on cases requiring 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

What You'll Need:

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
• Awarded Board Certification at least once in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
• Active medical state licensure preferred for PA, NY, or WV, but will consider other US states, if candidate agrees to get licensed in PA
• 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
• Strong skills in Critical Thinking, Case Management, Customer Service, Oral & Written Communication, Collaboration, Listening, Telephone Skills, General Computer Skills, Clinical Software, and Managed Care

• 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

Physical Demands:

• Ability to safely and successfully perform the essential job functions consistent with the ADA and other federal, state, and local standards
• Ability to conduct repetitive tasks on a computer, utilizing a mouse, keyboard, and monitor
• Must be able to communicate with customers/team members over the phone and in person
• Sedentary work that involves sitting or remaining stationary most of the time with occasional need to move around the office to attend meetings, etc.

Reasonable accommodation statement: If you require a reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employment selection process, please direct your inquiries to View email address on click.appcast.io or View phone number on click.appcast.io.

EEO Statement: It is the policy of Computer Aid, Inc. (CAI) not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or because he or she is a protected veteran. It is also the policy of CAI to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Employees and applicants of CAI will not be subject to harassment on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or because he or she is a protected veteran. Additionally, retaliation, including intimidation, threats, or coercion, because an employee or applicant has objected to discrimination, engaged or may engage in filing a complaint, assisted in a review, investigation, or hearing or have otherwise sought to obtain their legal rights under any Federal, State, or local EEO law is prohibited.

$160-$170 per hour. The pay range for this position is listed above. Exact compensation may vary based on several factors, including location, experience, and education. Benefit packages include medical, dental, and vision insurance, as well as 401k retirement account access. Employees in this role may also be entitled to paid sick leave and/or other paid time off as provided by applicable law.