Medical Director – Medicaid
Humana
Field Medical Director – Vascular Surgery
Evolent
full-time
Posted on:
Location: 🇺🇸 United States
Visit company websiteJob Level
Lead
About the role
- Key member of the utilization management team handling vascular surgery cases
- Serve as the specialty match reviewer for vascular cases and other imaging requests when specialty review is required
- Discuss determinations (peer-to-peer calls) with requesting physicians within regulatory timeframes
- Provide clinical rationale for standard and expedited appeals
- Utilize medical/clinical review guidelines and parameters to ensure appropriate utilization and compliance with SBU policies, URAC, and NCQA
- Act as a resource to Initial Clinical Reviewers and participate in inter-rater reliability training
- Ensure documentation of all communications with medical office staff and/or MD providers in a timely and accurate manner
- Assist Senior Medical Director with research related to Utilization Management and may function as Medical Director for selected plans/regions on request
- Non-clinical role offering improved work-life balance and remote work from home
Requirements
- MD/DO/MBBS - Required
- Current, unrestricted clinical license in medicine or required specialty - Required
- Obtain and maintain medical licenses in the state you reside - Required
- Active Board Certification in Vascular Surgery or Active Board Certification in General Surgery with extensive experience in Vascular Surgery - Required
- Minimum of five (5) years’ experience in the practice of Vascular Surgery - Preferred
- Strong clinical, management, communication, and organizational skills - Required
- Energetic and curious with a passion for quality and value in health care - Required
- Computer Proficiency - Required
- Ability to perform peer-to-peer discussions and provide clinical rationale for appeals
- Familiarity with Utilization Review Accreditation Commission (URAC) and NCQA guidelines
- High-speed internet over 10 Mbps and ability to plug directly into home internet router (technical requirement)
- May require identity verification for HIPAA compliance (identity verification collected for applicants advancing to final interview)
