Medical Director

Medical Director – Utilization Management

As part of a physician team, the Medical Director ensures utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of requested treatments or services. Depending on the nature of the case, telephonic peer-to-peer discussions may be required. The Medical Director ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of a multidisciplinary team for case and disease management and advises the team on high-risk and complex cases. Special projects may also be assigned to support and improve member care.

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 determinations, appeals, grievances, and other reviews as assigned.
• Compose clear and concise rationales for provider and member determination notifications while adhering to required compliance standards including NCQA, URAC, CMS, DOH, and DOL regulations.
• Ensure 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 teams on cases requiring physician expertise.
• Participate in protocol and guideline development to ensure consistency in the review process.
• Manage projects and/or participate on project teams requiring physician subject matter expertise.
• Preference will be given to candidates with payer-side Utilization Management experience within a health insurance environment. Candidates with only hospital-side UM experience may not meet requirements.

Required Qualifications

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO).
• Minimum 5 years of direct patient care experience in hospital, outpatient, or private practice settings.
• Board Certification in a 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.
• Expected productivity: 55+ cases completed in an 8-hour day.
• Critical thinking skills.
• Case management experience.
• Customer service skills.
• Strong oral and written communication skills.
• Collaboration and listening skills.
• Telephone skills.
• General computer skills.
• Experience with clinical software.
• Managed care experience.

Preferred Qualifications

• Master's Degree in Business Administration/Management or Public Health.
• Minimum 1 year of Medical Management experience within a Health Insurance Plan.
• Strong knowledge of the managed care industry.
• Experience with MCG or InterQual.

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 16 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.