Remote Medical Director — Utilization & Policy Leader

CAI; Hartford (CT); Remote; USD 234.000 - 276.000; Vollzeit

Benefits dieser Stelle

Medical insurance

Dental insurance

Vision insurance

401(k) retirement plan

Paid time off

Zusammenfassung

CAI is seeking a Medical Director to ensure utilization management responsibilities are performed in accordance with the highest and most current clinical standards. This is a full-time remote role supporting healthcare operations.

The position requires an MD/DO, board certification, active state licensure, and at least 5 years of direct patient care experience, with strong critical thinking and communication skills essential for success.

Qualifikationen

• MD or DO required.
• Board certification in a specialty recognized by ABMS or AOA required.
• Active medical state licensure required for PA, NY, or WV.
• 5 years in Clinical, Direct Patient care.
• Strong skills in critical thinking, case management, customer service, oral & written communication, collaboration, listening, telephone skills, general computer skills, clinical software, and managed care.

Aufgaben

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness.
• Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned.
• Compose clear and concise rationales for members and provider determinations while adhering to compliance standards (NCQA, URAC, CMS, DOH, DOL).
• Ensure all aspects of the medical management process align with community standards of care.
• Participate as a CMDM team member: attend huddles and grand rounds, advise on cases needing physician input.
• Participate in protocol and guidelines development for consistency in reviews.
• Manage projects or participate on project teams requiring physician SME.

Kenntnisse

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Ausbildung

MD/DO

Board Certification

Active medical state license

Jobbeschreibung

CAI is seeking a Medical Director to ensure utilization management responsibilities are performed in accordance with the highest and most current clinical standards. This is a full-time remote role supporting healthcare operations.

The position requires an MD/DO, board certification, active state licensure, and at least 5 years of direct patient care experience, with strong critical thinking and communication skills essential for success.