[Hiring] Medical Director – Clinical Ops Case Review @Medica

Role Description

The Medical Director – Clinical Operations has the responsibilities of supporting care management, quality, utilization management, credentialing, pharmacy, health policy implementation, technology assessment and risk management activities. This position requires a solid medical and business mind, with strong judgment and investigative nature, and an ability to develop medical policy that effectively balances provider, patient, and health plan interests. This person also works to bring consistency to all aspects of the decision-making surrounding the above noted activities. Performs other duties as assigned.

Key Accountabilities

• Care Management and Appeals Decisions Participation
  • Completes care management case review for cases involving medical necessity review, including standard and expedited pre-service, concurrent and post-service decisions.
  • Completes appeal case review for cases involving medical necessity review, including standard and expedited pre-service, concurrent and post-service decisions.
  • Participates in rotation to above referenced decisions, and Clinical Grand Rounds with nurses.
  • Participates in review of coding appeal.
  • Participates as needed in facility claims audit.
  • Conducts review of the denial of ER services.
• Care Management Program and Initiatives Participation
  • Partners to establish priorities as appropriate for improving service at the point of care.
  • Participates in case review inter-rater reliability process, as appropriate.
  • Assists with review of data on utilization to identify potential over-, under- and mis-utilization of care.
  • Assists with identifying interventions based on the information above.
  • Participates in quality-of-care complaint inter-rater reliability process, as appropriate.
  • Participates in on-call weekend/holiday coverage for Medicare Part D and expedited reviews.
  • Serves as a reviewer on Clinical Appeals cases.
  • Provides support to Medica’s case management programs.
• Quality of Care Complaints Participation
  • Completes quality of care complaint reviews for cases involving clinical aspects or clinical/service aspects.
  • Participates in rotation to above.
• Committee Participation
  • Participates in the technology assessment and benefit determination processes, as required.
  • Chairs Medica’s Technology Assessment Committee and/or may be asked to participate in Committees as required.
  • Serves as clinical representation to Medica’s Benefit Implementation Committee.
  • Prior Authorization Work Group.

Qualifications

• Medical Doctorate (MD) or Doctor of Osteopathic Medicine (DO).
• 10+ years of experience beyond degree.
• 5+ years of leadership experience.

Requirements

• Must be a licensed physician with current Board certification of ABMS recognized specialty.
• Current medical license to practice must be without restrictions.
• Must be willing and able to successfully apply for medical license in other states as needed.

Preferred Qualifications

• Demonstrated proficiency in pre-service review, concurrent review, post-service review, case management and appeals.
• Knowledge of pharmacy and therapeutics process, including prior experience in formulary development and utilization review is very desirable.
• Outstanding written, verbal and communications skills.
• Strong collaboration skills.
• Technical aptitude.
• Ability to represent Clinical on various Medica Committees.
• Strong process management skills.
• Strong ability to utilize various application technology systems.
• Excellent leadership skills.
• Customer service orientation - must enjoy speaking to network physicians.
• Actively influences and drives discussions toward resolution - shows good judgment and decisiveness.

Benefits

• Competitive medical, dental, vision.
• PTO, Holidays, paid volunteer time off.
• 401K contributions.
• Caregiver services.
• Many other benefits to support our employees.

Eligibility to work in the US

Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

Equal Opportunity Employer

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.