Medical Director - Post-Acute Care - EviCore - Remote

The Cigna Group; United States; Remote; USD 203,000 - 339,000; Full time

Job summary

A leading healthcare company is seeking a Utilization Review Medical Principal. This role involves expert medical review of clinical services, engaging with physicians, and maintaining clinical guidelines. Candidates must have an M.D. or D.O. and relevant experience. Comprehensive benefits and a competitive salary are offered.

Benefits

Comprehensive benefits including medical, vision, dental

401(k) with match

Paid time off

Holidays

Qualifications

• At least five years of post-training clinical practice, including residency and fellowship if applicable.
• Unrestricted license to practice medicine in a U.S. state or territory as a utilization review physician.

Responsibilities

• Provide expert medical review of medical necessity requests for post-acute care.
• Engage in peer-to-peer discussions with treating physicians to clarify clinical information.
• Document all actions related to clinical reviews and attest to review qualifications.

Skills

Proficient in computer skills

Knowledgeable in Microsoft Office

Ability to type 30 WPM

Education

M.D. or D.O. from an accredited institution

Active board certification in Physical Medicine and Rehabilitation

Job description

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

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Summary:

The Medical Director provides timely expert medical review of medical necessity requests for clinical services that do not meet utilization review criteria and offers a clinical opinion about the reviewed service while located in a U.S. state or territory.

Responsibilities include:

1. Provide expert medical review of medical necessity requests for post-acute care and render clinical opinions, including post-decision reviews.
2. Engage in peer-to-peer discussions with treating physicians to clarify clinical information and explain review outcomes.
3. Participate in proactive peer-to-peer efforts to facilitate appropriate and timely discharge planning.
4. Document all actions related to clinical reviews and attest to review qualifications as required.
5. Conduct weekly case conferences with nursing and social work teams focusing on discharge planning, complex medical care, quality, and appropriate levels of care and stay durations.
6. Maintain necessary credentials and promptly inform eviCore of any adverse actions related to medical licenses or certifications.
7. Support review and development of eviCore clinical guidelines.
8. Communicate eviCore policies and procedures to the provider community.
9. Testify at ALJ hearings when cases are appealed.
10. Assist with staff training and serve as a clinical resource for eviCore staff.
11. Serve as a Subject Matter Expert when Medical Directors are unavailable.
12. Be available for scheduled weekend calls from home, based on business needs.
13. Participate in Joint Operating Committee (JOC) meetings and other virtual provider engagement activities in your territory.
14. Engage in educational and quality improvement activities, maintaining passing scores.
15. Review case determinations in response to provider or member complaints.

Minimum Education, Licensure, and Certification:

• M.D. or D.O. from an accredited institution.
• At least five (5) years of post-training clinical practice, including residency and fellowship if applicable.
• Active board certification in Physical Medicine and Rehabilitation.
• Unrestricted license to practice medicine in a U.S. state or territory as a utilization review physician.
• Knowledge of relevant laws, URAC, NCQA standards, and utilization management.

FLSA: Exempt

Bonus Plan: Corporate Incentive Plan (CIP) for exempt team members

Employment Status: Full-time, 1.0 FTE, 5 days/week schedule

Skills Required: Ability to type 30 WPM, proficient in computer skills, and knowledgeable in Microsoft Office. Internet connection must be via cable broadband or fiber optic with speeds of at least 10Mbps download/5Mbps upload.

Anticipated annual salary ranges from $203,200 to $338,600, depending on experience and location. The role may also be eligible for an annual bonus.

Benefits:

Comprehensive benefits including medical, vision, dental, well-being programs, 401(k) with match, paid time off, holidays, and more. Details available at Life at Cigna.

We are an equal opportunity employer, considering qualified applicants without regard to race, color, age, disability, sex, or other protected characteristics.

Please ensure you meet our posting guidelines to be eligible for consideration. More info at the provided link.

Criminal history considerations are handled in accordance with applicable laws.