Medical Director
Yesterday
Description
• This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. • The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service. • Depending on the nature of the case, telephonic peer to peer discussions may be required. • The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times. • In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management. • They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. • Additionally, the incumbent may be assigned special projects to help support and improve the care of our members.
Requirements
• Required Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) • 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice) • Active medical state licensure required.
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