Medical Director - Orthopedic Surgeon

The Cigna Group; United States; Remote; USD 206,000 - 344,000; Full time

Job summary

A leading healthcare organization seeks a Medical Principal to provide clinical review and case management. This entry to mid-level position focuses on improving patient outcomes while managing claims and consultations. Responsibilities include participating in medical necessity reviews and enhancing relationships with healthcare professionals. Candidates must have a medical license, board certification, and at least five years of clinical practice experience. Competitive salary and comprehensive benefits offered.

Benefits

Medical, vision, and dental insurance

401(k) with company match

Tuition reimbursement

At least 18 days of paid time off per year

Paid holidays

Qualifications

• Minimum of 5 years of clinical practice experience and/or direct patient care beyond residency.
• Ability to balance patient advocacy with business needs.
• Fluency in Spanish or other languages preferred.

Responsibilities

• Performs medical necessity reviews for coverage and case management.
• Implements clinical insights to improve outcomes through communication.
• Participates in quality auditing and clinical reviews.

Skills

Communication

Negotiation

Problem-solving

Teamwork

Education

Current unrestricted medical license in a US state or territory

Current board certification in an ABMS or AOA recognized specialty

Tools

Microsoft Word

Spreadsheet software

Email client

PowerPoint

Job description

The job profile for this position is Medical Principal, which is a Band 5 Senior Contributor Career Track Role.

Excited to grow your career?

We value our talented employees, and whenever possible strive to help one of our associates grow professionally before recruiting new talent to our open positions. If you think the open position you see is right for you, we encourage you to apply!

Our people make all the difference in our success.

Position scope:

Primarily regional with national level case work for Cigna Healthcare (CHC) -- Cigna.

Summary description of position: A Medical Principal performs medical review and case management activities. The physician provides clinical insight to the organization through peer review, benefit review, consultation, and service to internal and external customers. He/she will serve as a clinical educator and consultant to utilization management, case management, network, contracting, pharmacy, and service operations (claims). This is an entry to mid-level position for a physician interested in a career in health care administration.

Major responsibilities and required results:

• Performs benefit-driven medical necessity reviews for coverage, case management, and claims resolution, using benefit plan information, applicable federal and state regulations, clinical guidelines, and best practice principles.
• Works to achieve quality outcomes for customers/members with a focus on service and cost
• Improves clinical outcomes through daily interactions with health care professionals using active listening, education, and excellent communication and negotiation skills.
• Balances customer/member needs with business needs while serving as a customer/member advocate at all times.
• Participates in all levels of the Appeal process as appropriate and allowed by applicable regulatory agencies and accreditation organizations
• Participates in coverage guideline development, development and maintenance of medical management projects, initiatives and committees.
• Participates in quality processes such as audits, inter-rater reliability clinical reviews, and quality projects
• Serves as a mentor or coach to other Medical Directors and other colleagues in quality and performance improvement processes.
• Improves health care professional relations through direct communication, knowledge of appropriate evidence-based clinical information and the fostering of positive collegial relationships.
• Demonstrates knowledge as a peer reviewer by applying current evidence-based guidelines, including novel treatments, to support high-quality clinical decision-making across medical and behavioral health conditions, diseases, treatments, and procedures. Medical directors are required to maintain and update their knowledge base through monthly focused updates of Cigna's comprehensive evidence-based coverage policies, as well as through mandatory inter-rater reliability testing, continuing medical education, and maintenance of board certification.
• Addresses customer service issues with mentoring and support from leadership staff.
• Investigates and responds to client and/or regulatory questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff.
• Achieves internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions.
• Provides clinical insight and management support to other functional areas and matrix partners as needed or directed.

Minimum Requirements:

• Current unrestricted medical license in a US state or territory.
• Current board certification (lifetime certification or certification maintained by MOC or other applicable program) in an ABMS or AOA recognized specialty
• Exhibits ethical and professional behavior.
• Minimum of 5 years of clinical practice experience and/or direct patient care beyond residency
• Computer Competency: Word processing, Spreadsheet, Email, PowerPoint and Personal Information Management programs are used extensively and competency in all must be possessed or rapidly acquired.
• Must not be excluded from participation in any federal health care program**
• Must not be included in CMS’ Preclusion List**

Preferred Skill Sets:

• Experience in medical management, utilization review and case management in a managed care setting.
• Knowledge of managed care products and strategies.
• Ability to work within changing business environment and balance patient advocacy with business needs.
• Experience with managing multiple projects in a fast-paced matrix environment.
• Demonstrated ability to educate colleagues and staff members.
• Successful experience and comfort with change management.
• Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem-solving skills.

• Successful ability to assess complex issues, to determine and implement solutions, and resolve problems.
• Success in creating and maintaining cooperative, successful relations with diverse internal and external stakeholders.

• Demonstrated sensitivity to culturally diverse situations, participants, and customers/members.
• Service marketing, sales, and business acumen experience a plus.
• Fluency in Spanish (Cigna Medicare) or other languages

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.For this position, we anticipate offering an annual salary of 206,300 - 343,900 USD / yearly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan and long term incentive plan.

We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

Please note that you must meet our posting guidelines to be eligible for consideration. Policy can be reviewed at this link.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.