Medical Director
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Job Description
Medical Director leading clinical oversight and utilization management for Home Health, DME, Home Infusion Therapy, and Sleep Medicine. Conducting medical necessity reviews and collaborating with health plan leadership.
Responsibilities:
- Provides clinical oversight and utilization management for Home Health, Durable Medical Equipment (DME), Home Infusion Therapy, Sleep Medicine, and related services.
- Conducts medical necessity reviews using industry-standard clinical criteria and evidence-based guidelines to support coverage determinations and quality care outcomes.
- Conducts efficient medical necessity reviews and peer to peer consultations in adherence with regulatory and compliance turnaround times on cases that may not meet clinical criteria.
- Issues adverse determinations as needed.
- Provides guidance to licensed and non-licensed associates on clinical issues and case reviews related to authorization requests and clinical guidelines criteria.
- Completes peer to peer discussions when medical necessity criteria are not met.
- Participates in CareCentrix Care Coordination, Utilization Management, Quality Improvement and clinical education activities, as requested.
- Utilizes clinical integrity in all determinations and interactions with internal and external partners.
- Collaborates with Health Plan clinical leadership as requested.
- Achieves Service Level Agreement (SLA) metrics and performance guarantees as required by health plan clients.
- Participates and supports different committees and clinical rounds as necessary or assigned.
Requirements:
- MD or DO with an active and unencumbered medical license.
- Must have active ABIM or ABMS specialty board certification(s).
- Minimum of 5 years’ experience in an area of relevant clinical practice.
- At least 3 years’ experience with supporting utilization management reviews, managed care programs or care delivery networks.
- Expertise in Home Health, DME and sleep fields, including current knowledge on best practices.
- General knowledge of regulatory and accreditation standards for payers and health care providers.
- Expertise in Health Plan or Payer Utilization Management (UM)
- Strong team player with the ability to collaborate effectively across multidisciplinary teams and stakeholders.
- This position requires excellent written and verbal communication skills.
- Conveys a strong professional image, exhibits interest quality improvement, and projects a positive attitude toward all assigned work.
- Adheres to and participates in Company's mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.
Benefits:
- Paid Flex Time Off (FTO)
- 401K Savings Plan
- Paid Parental Leave
- Medical
- Dental
- Vision
- HSA employer contributions
- Dependent Care FSA employer contribution
- Paid Time Off
- Personal/Sick Time
- Award winning culture
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