Medical Director – Medicaid
Humana
Field Medical Director, MSK Surgery
Evolent
full-time
Posted on:
Location: 🇺🇸 United States
Visit company websiteJob Level
Lead
About the role
- Key member of the utilization management team providing non-clinical review support
- Serve as the Physician match reviewer for Hip/Knee/Shoulder Surgery cases and other imaging requests requiring specialty review
- Discuss determinations (peer-to-peer calls) with requesting physicians/providers within regulatory timeframes and provide clinical rationale for appeals
- Utilize medical/clinical review guidelines and parameters to ensure consistency and compliance with SBU policies, URAC and NCQA guidelines
- Aid and act as a resource to Initial Clinical Reviewers
- Ensure documentation of all communications with medical office staff and/or MD providers is timely and accurate
- May assist the Senior Medical Director in research activities related to Utilization Management, interpretation, guidelines and/or system support
- Participate in on-going training per inter-rater reliability process
- Opportunity to make a meaningful difference in patients’ lives in a non-clinical environment
Requirements
- MD/DO/MBBS
- Minimum of five (5) years’ experience in the practice of Medicine, post residency
- Active clinical practice within the last 2 years is highly preferred
- Current, unrestricted clinical license in medicine or required specialty
- Obtaining and maintaining medical licenses in the state you reside, as well as any license required per business needs
- Active Board Certification in Orthopedic Surgery
- Strong clinical, management, communication, and organizational skills
- Energetic and curious with a passion for quality and value in health care
- Computer proficiency
- Not under current exclusion or sanction by any state or federal health care program (including Medicare or Medicaid) and not identified as an “excluded person” by OIG or GSA
- No history of a major disciplinary or legal action by a state medical board
- Compliance with HIPAA identity verification may be required as part of application process
- Home technical requirements: High speed internet over 10 Mbps and ability to plug directly into the home internet router (for call center employees)
