Summary:
- The Medical Director provides timely expert medical review of medical necessity requests for clinical services that do not meet utilization review criteria and renders a clinical opinion about the medical service under review while located in a state or territory of the United States.
Responsibilities include:
- Provide timely expert medical review of medical necessity requests for clinical services related to post-acute care and render a clinical opinion about the medical service under review, including post-decision reviews.
- Provide timely and collegial peer-to-peer discussions with treating physicians to clarify clinical information and to explain review outcome decisions.
- Participate in proactive peer to peers to assist with appropriate and timely discharge planning.
- Document all actions related to clinical review sessions and attest to review qualifications as required.
- Conduct weekly Case Conferences with nursing and social worker teams; discussing every assigned member receiving care in a post-acute care facility, focusing on discharge planning, complex medical care management, quality of care, appropriate level of care, and appropriate length of stay.
- Maintain necessary credentials and immediately inform eviCore of any adverse actions relating to medical licenses and/or board certifications.
- Support the review of eviCore clinical guidelines.
- Support and communicate eviCore policies and procedures to the provider community.
- Testify at ALJ Hearings when your cases are being appealed
- Assist with staff educational training and in-service programs and serve as a clinical resource for eviCore staff.
- Serve as a Subject Matter Expert when Medical Directors and/or Senior Medical Directors are unavailable.
- Available for scheduled weekend call from home based on business needs.
- Participate in Joint Operating Committee (JOC) meetings, including the collection and review of data relevant to the client, and other virtual events with the provider engagement team in your specified territory.
- Participate in all required educational and quality improvement activities and maintain passing scores in all assessments.
- Assist in reviewing case determinations from clients responding to a provider or member complaint
- Maintain necessary credentials and immediately inform eviCore of any adverse actions relating to medical licenses and/or board certifications
- Other duties as assigned
Minimum Education, Licensure and Professional Certification requirement:
- M.D or D.O with active board certification in primary care specialties (Family Medicine, Internal Medicine or Emergency Medicine) OR board certification in Physical Medicine and Rehabilitation required (recognized by the American Board of Medical Specialties or American Osteopathic Association)
- Three (3) or more years of relevant clinical practice post residency/fellowship required
- 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
- Ability to commit to a set, weekly work schedule (Monday through Friday)
- Strong computer skills: ability to work autonomously with automated processes, computer applications, and systems
- Meet physical demands of the role including, but not limited to, typing, speaking, and listening 100% of the time
- In accordance with our HITECH Security Accreditation, company provided encrypted-workstation is required to be hard-wire connected to a modem or router. Wireless connection is not permitted.
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.For this position, we anticipate offering an annual salary of 203,200 - 338,600 USD / yearly, depending on relevant factors, including experience and geographic location.
This role is also anticipated to be eligible to participate in an annual bonus plan.
We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group.
About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
