Medical Director

• Provides administrative oversight to the medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on medical policies
• Writes and revises medical policies
• Supports operations in case review on medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Educates staff and medical community on medical policy and program administration
• Develops and updates medical policy in consultation with regulatory personnel, medical consultants, and professional societies
• Develops external relationships with the medical community
• Reviews physician and provider practice pattern analysis and statistical data related to medical service utilization
• Conducts research into new or controversial medical procedures and technology

Physical Medicine and Rehabilitation Medical Director

• Oversee the performance and growth of Customer Service, Prescription Processing, Client-specific teams, managing both internal staff and external vendors
• Lead operational excellence across central fill pharmacy networks and courier delivery operations
• Lead your team with Key Performance Indicators (KPIs) to drive business success and increase efficiency while lowering the cost-to-fill on an annual basis
• Manage quality, turnaround time (TAT), and customer satisfaction metrics to ensure FuzeRx remains the preferred infrastructure partner for telehealth and pharma partners
• Establish requirements for capabilities and reporting, collaborating cross-functionally to deliver data-driven insights
• Analyze data to forecast staffing needs based on program performance, optimizing resource allocation across multiple roles
• Lead a large team of managers, supervisors and team members, establishing an environment of positive employee engagement and experience

Director, Rx Clinical Operations

• Provides administrative oversight to the medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on issues concerning medical policies
• Supports operations in the form of case review on both medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Provides input on issues and operational policies, processes, and procedures
• Educates staff and medical community on various aspects of medical policy and program administration
• Develops and updates medical policy in consultation with regulatory personnel, medical consultants, and professional societies
• Develops external relationships with the medical community and serves as liaison between these entities and the contractors
• Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization
• Conducts research into new or controversial medical procedures and technology

• Provides administrative oversight to medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on medical policy issues
• Writes and revises medical policies
• Supports operations in case review on medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Provides input on issues and operational policies, processes, and procedures
• Educates staff and medical community on medical policy and program administration
• Develops and updates medical policies in consultation with regulatory personnel and consultants
• Develops external relationships with the medical community
• Reviews physician and provider practice pattern analysis and other statistical data
• Conducts research into new or controversial medical procedures and technology

• Manage the Health Plan Medical Directors
• Provide clinical support for the Health Management Utilization Management, Care Management and Quality teams
• Drive the development, promotion and delivery of high quality, evidence-based utilization and care management programs and processes
• Lead programs and reviews to support effective medical expense management, medical quality programs and outcomes, and programs to manage medical utilization trends such as inpatient, Emergency Department, Site of Care, pharmacy and radiology
• Achieves defined clinical outcomes, affordability goals and growth targets
• Works closely across the HP to ensure compliance with government program regulations, including management of clinical appeals and grievances with sound clinical evidence and advice
• Works closely with the Medical Directors and the Director of Medical Economics to devise analytic approaches that support and measure strategic development and sound clinical programs
• Provides clinical insight into data to assist in development of and measurement of tailored interventions that address clinical trends and opportunities
• Develops key strategies to address opportunities in medical expense management
• Identifies opportunities for improvement in the quality of care that create competitive advantage for Martin’s Point as it relates to the health of populations served
• Accountable for appropriate Utilization Management processes
• Assists and provides clinical input into the evolution of care/utilization management, quality, and pharmacy related programs
• Contributes to and advises in product design and the Medicare bid processes
• Contributes to and advises in areas of clinical integration as it relates to risk adjustment
• Serves as a central HP leader aligning medical, clinical, and operational functions to achieve seamless and thorough solutions related to Medical and Payment Policies
• Actively engages with quality, network, and compliance teams to help drive performance

Vice President, Medical Director of Clinical Programs

• participate in the development, implementation, and evaluation of clinical / medical programs
• expand Aetna's medical management programs to address member needs across the continuum of care
• support the Medical Management staff ensuring timely and consistent responses to members and providers
• provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities
• act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams

Medical Director – Commercial

• Leverage your background in Pain Medicine disciplines to deliver evidence-based medical reviews that support high-quality patient care.
• Collaborate with healthcare providers and stay current on healthcare regulations and industry developments as you review a wide range of cases.
• Start training remotely in a structured environment with support from trainers, mentors, and leadership to set you up for success.
• Complete time-sensitive, specialized evidence-based medical case reviews for medical necessity on EviCore’s case management software.
• Conduct physician consultation (peer-to-peer) calls with referring providers to discuss evidence–based medical necessity and appropriateness of the requested service or treatment.
• Leverage your clinical expertise to recommend alternative services or treatments as necessary.
• Work collaboratively with over 500 EviCore physician colleagues to help ensure patients receive proper care via evidence-based decision making.

Medical Director jobs in Vermont

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Physical Medicine and Rehabilitation Medical Director

Director, Rx Clinical Operations

Physical Medicine and Rehabilitation Medical Director

Physical Medicine and Rehabilitation Medical Director

Vice President, Medical Director of Clinical Programs

Medical Director – Commercial

Medical Director – Pain Medicine