Medical Director

The Medical Director is responsible for actively participating in the review process of pre-service requests for services, and following guidelines in the approval of those services or in making recommendations for other determinations to the provider/vendor (denial/modification/redirection). Additionally, the role will cooperate with and support the other physician reviewers, nurses, and Medical Directors by knowing all processes and procedures, while working to deliver excellent care cost-effectively based on medical management referral processing guidelines. The Medical Director will be detail-oriented and able to research and successfully evaluate often-complex clinical information to help formulate decisions and communicate with members, providers, and internal users. Understand, promote, and manage the principles of medical management to facilitate the right care for patients at the right time and in the right setting As part of a team of medical directors, nurses, and coordinators participate in the pre-service medical necessity review of patient care Review prior authorization requests for medical necessity using appropriate clinical guidelines Identify high-risk patients and help coordinate care with the Employer’s high-risk team From time to time, meet with individual primary care physicians, specialists, and/or provider groups to review best practices for patient care Perform prior authorization functions for various Employer campuses, should the need arise in cross coverage, secondary/tertiary review, or medical director decision-making Perform retroactive claims review for outpatient and inpatient care, as needed Provider Relations Physician shall Work with the Employer’s network management team to establish and maintain provider relations Be a direct resource to the IPA providers on issues related to UM and other aspects of patient care Quality/Grievance and Appeals Physician shall Understand the Employer and its affiliates’ internal programs for Q/G&A and may review and respond to G&A and peer review Participate in meetings to review, develop, and continually improve internal quality improvement and peer review processes and programs Perform verbal counseling to IPA providers after G&A determinations for corrective action plans and follow-ups Job Requirements Doctor of Medicine degree Specialty training and/or managed care experience preferred Minimum of five years of prior clinical experience required, with at least two years of managed-care or health-plan experience preferred Must demonstrate a strong clinical fund of knowledge Must have familiarity with the principles of clinical research and have the ability to interpret and apply clinical guidelines and policies Strong proficiency in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point) and ability to conduct research over the internet #J-18808-Ljbffr