Executive Medical Director, DME/IRF
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Job Description
Medical Director overseeing EviCore’s DME and IRF utilization management programs. Leading clinical guidelines, physician supervision, audits, appeals, and medical necessity reviews.
Responsibilities:
- Oversee intraday activities of EviCore’s Durable Medical Equipment and Inpatient Rehabilitation Facility management programs and services
- Serve as program internal lead for DME clinical guideline and policy management
- Work with the Guideline Manager to create EviCore DME guidelines
- Maintain and update DME denial rationales
- Represent EviCore in Medicare or Medicaid DME and IRF audits and case discussions
- Support development of DME clinical pathways with the pathways team
- Create quarterly DME IRR quizzes and hold physician debriefs
- Assist in case audits assessing Associate Medical Directors’ and Medical Directors’ decision-making accuracy and adherence to EviCore criteria and processes
- Hold regular 1:1 meetings with DME/IRF Associate Medical Directors and Medical Directors
- Provide weekend coverage for urgent DME and IRF appeals
- Testify at ALJ hearings when cases are appealed or the adjudicating Associate Medical Director is unavailable
- Provide audit support for DME and IRF cases reviewed during CMS and client audits
- Assist with interviewing, onboarding, and training new DME/IRF Associate Medical Directors
- Serve as subject matter expert and first point of contact for problematic or escalated case reviews
- Respond to urgent, expedited, or escalated DME and IRF cases and P2Ps
- Review client case determinations related to provider or member complaints
- Respond to notifications and requests to amend incorrect reviews when the original physician reviewer is unavailable
- Manage day-to-day clinical activities of the EviCore DME/IRF Program
- Collaborate with Clinical Operations, Non-clinical Operations, and Program Operations leadership to optimize program functioning
- Supervise and manage DME/IRF Medical Directors and Associate Medical Directors
- Support development and maintenance of EviCore policies, procedures, and clinical certification criteria
- Coordinate clinical development and education through educational materials and quarterly sessions
- Evaluate Medical Directors’ and Associate Medical Directors’ performance
- Coach, mentor, and/or clinically supervise designated Medical Directors and Associate Medical Directors
- Support review of EviCore clinical guidelines
- Support sales and client management teams as clinical representative when requested
- Provide expert medical necessity reviews and clinical opinions, including post-decision reviews
- Maintain necessary credentials and report adverse actions involving medical licenses or board certifications
- Communicate EviCore policies and procedures to the provider community
- Participate in required educational and quality improvement activities and maintain passing assessment scores
- Perform other duties as assigned
Requirements:
- M.D. or D.O. degree from accredited institution
- Minimum of five (5) years of clinical practice experience after completion of all graduate medical education training, including residency and fellowship (when applicable)
- Active board certification in Physical Medicine & Rehabilitation
- Active unrestricted license to practice medicine in a state or territory of the United States as a utilization review doctor of medicine or doctor of osteopathic medicine
- Knowledge of applicable state and federal laws, URAC and NCQA standards, and utilization management
- Two (2) or more years of managed care experience
- Familiarity with automated processes and computer applications and systems
- Supervisory and/or management experience strongly preferred
- Internet connection through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload when working at home
Benefits:
- Annual bonus eligibility
- Long term incentive plan eligibility
- Medical benefits
- Vision benefits
- Dental benefits
- Well-being and behavioral health programs
- 401(k)
- Company-paid life insurance
- Tuition reimbursement
- Minimum of 18 days of paid time off per year
- Paid holidays
- Leaves of absence
- Remote work arrangement
- Cable broadband or fiber optic internet service with at least 10Mbps download/5Mbps upload for home working
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