[Hiring] SVP Medical Director @Sedgwick

Role Description

To evaluate medical reports escalated due to deficient information utilizing evidence-based criteria; to provide leadership within the dedicated team of clinician and claim professionals in support of the dedicated program through training and implementation of medical best practices; and to provide client-facing support when needed for additional services supporting Human Resources with ADAAA and FMLA support that require medical expertise; to adhere to service delivery time frames, customer satisfaction, and overall support of workflow.

Qualifications

• Medical Doctor (M.D.) degree required.
• Ten (10) years of related experience required, including one (1) to three (3) years of utilization review experience and three (3) years of clinical quality control.
• Knowledge of evidence-based guidelines.
• Knowledge of ADAA and FMLA.
• Knowledge of utilization review procedures.
• Knowledge of clinical quality systems and measurements.
• Knowledge of resources available regarding regulations and parameters of third-party reimbursement, benefit determinations, and payments.
• Knowledge of statutory requirements of state's jurisdiction/ERISA regulations.
• Knowledge about general claim practices.
• Knowledge of pharmacy processes and pharmacy benefit management a plus.
• Understanding of pain management a plus.
• Excellent oral and written communication skills, including presentation skills.
• PC literate, including Microsoft Office products.
• Analytical and interpretive skills.
• Strong organizational skills.
• Excellent interpersonal skills.
• Proven management/leadership skills.
• Ability to create and complete comprehensive, accurate, and constructive written reports.
• Ability to work in a team environment.
• Ability to meet or exceed Performance Competencies.

Requirements

• Client-facing clinical support: Participate in client stewardship discussions, claim roundtables, and complex medical escalations.
• Travel Expectations: 25%-30%.
• Emerging medical trends and clinical strategy: Stay current on emerging medical trends, treatment standards, clinical literature, and evidence-based guidelines; support client conversations and operational decisions tied to these trends.
• Claims and occupational health expertise: Support workers’ compensation, disability, FMLA, fitness-for-duty, return-to-work, liability, and safety-sensitive workforce issues.
• Managed Care / UR support: Can support operational needs as required specific to Utilization Review and Physician Advisor Support, care management strategy, vendor alignment, and quality improvement.
• Licensure support: Obtain and maintain Medical Director licensure in a few select states, as needed, to support regulatory, Managed Care, utilization review, and operational requirements.
• Evidence-based medical guidance: Apply applicable clinical guidelines and medical literature to support defensible recommendations, claim discussions, treatment-plan clarification, and return-to-work/disability-related decision-making.
• Provider, appeal, and quality support: Engage treating providers when needed and support appeals, independent medical review considerations, peer review alignment, and clinical quality review.

Benefits

• Three medical, and two dental & vision plans to choose from.
• Tuition reimbursement.
• 401K plan that matches 50% on every $ you put in up to the first 6% you save.
• 4 weeks PTO your first full year.
• Offering a blended work environment.
• Supporting meaningful work that promotes critical thinking and problem solving.
• Providing ongoing learning and professional growth opportunities.
• Promoting a strong team environment and a culture of support.
• Recognizing your successes and celebrating your achievements.