The Medical Director plays a pivotal role in supporting the medical management staff to ensure timely and consistent medical decisions for our members and providers. This is a remote based (work from home) position. As a key member of our team, you will be responsible for medical management tasks, including clinical case reviews, medical necessity determinations, peer-to-peer conferences, appeal review, and policy adherence.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Conduct timely clinical utilization management reviews including Prior Authorization, Pre-certification,
Concurrent Reviews, and First Level Appeals - Initiate physician-to-physician calls to gather pertinent medical information for making medical necessity
determinations and conduct Peer to Peer calls as needed after first determination. - Assess and provide accurate clinical coding for care
- Ensure the consistent application of Curative medical policies, evidence-based medicine references, and
national guidelines in medical necessity decisions. - Participate in team activities to troubleshoot new initiatives and create a cohesive and enjoyable work
environment - Bring to the attention of supervisors cases requiring additional review, policy interpretation, high cost or
complex cases requiring coordination of care. - Work adhering to US regulatory and Quality System requirements (21 CFR 820, etc).
- Assumes and performs other duties as assigned.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The
requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions:
- Ability to work within a startup environment.
- Excellent verbal and written communication skills. Must be fluent in English.
- Expert knowledge of federal regulations governing claims payment, HIPAA regulations, workplace
ethics, and creation of a cohesive team environment. - At least two (2) years of experience in utilization management (insurance company managed care
experience preferred). - Superior knowledge of evidence-based guideline use for medical management, plan benefit design,
consistent application of medical necessity criteria, and use of data and performance metrics to ensure
value and optimal outcomes. - Demonstrable skills in successful conduct of peer-to-peer conversations.
- Knowledge of, or ability to learn individual state regulations (including but not limited to State of Texas
Department of Insurance (TDI) regulations and TDH). - Strong computer skills, particularly working with Google applications.
- Ability to communicate with all levels of staff including IT, nurses, and Executive Management.
REQUIRED EDUCATION AND CERTIFICATIONS
- MD or DO degree from an accredited medical school
- Board Certification in FP, Peds, Med-Peds, or IM, OR Board Certification is in a medical specialty.
- At least two (2) years of post-graduate clinical practice.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while
performing the essential functions of this job. Reasonable accommodations may be made to enable individuals
with disabilities to perform the essential functions.
❑ While performing the duties of this Job, the employee is regularly required to sit; use hands to handle or
feel; talk; and hear.
❑ Specific vision abilities required by this job include close vision, distance vision, color vision,
peripheral vision, depth perception and ability to adjust focus.
❑ The noise level in the work environment is usually: □ Mild
❑ For this position the percentage of expected Travel is: 5% of the time