Medical Director

Overview

The Medical Director provides clinical oversight and utilization management for Home Health, Durable Medical Equipment (DME), Home Infusion Therapy, Sleep Medicine, and related services. In this role, the Medical Director conducts medical necessity reviews using industry-standard clinical criteria and evidence-based guidelines to support coverage determinations and quality care outcomes.

Responsibilities

• 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, and 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, to facilitate proactive discharge planning or when facility stay is no longer medically indicated.
• 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

Qualifications

• 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, and 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, as well as a 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.

What We Offer

• Pay Range: $240000 – $280000 / year plus corporate bonus incentive.
• Paid Flex Time Off (FTO), 401K Savings Plan, Paid Parental Leave and more
• Benefits: Medical, Dental, Vision, 401(k) with company match, HSA employer contributions, Dependent Care FSA employer contribution, Paid Time Off, Personal/Sick Time, Paid Parental Leave, and more.
• Award winning culture that keeps our company values at the heart of everything we do: We Care; We Do the Right Thing; We Strive for Excellence; We Think BIG; We Take our Work Seriously, Not Ourselves.

CareCentrix maintains a drug-free workplace

We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.

CareCentrix accepts applications on an ongoing basis until a candidate is identified.

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Originally posted on Himalayas