Job Description

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

Clinical Advocacy & Support has an unrelenting focus on the customer journey and ensuring we exceed expectations. Our role is to empower providers and members with the tools and information needed to improve health outcomes, reduce variation in care, deliver seamless experience, and manage health care costs. 

The Medical Director provides physician support to Enterprise Clinical Services operations, the organization responsible for the initial clinical review of service requests for Enterprise Clinical Services.  The Medical Director collaborates with Enterprise Clinical Services leadership and staff to establish, implement, support and maintain clinical and operational processes related to benefit coverage determinations, quality improvement and cost effectiveness of service for members. The Medical Director's activities primarily focus on the application of clinical knowledge in various utilization management activities with a focus on pre-service benefit and coverage determination or medical necessity (according to the benefit package), and on communication regarding this process with both network and non-network physicians, as well as other Enterprise Clinical Services.

The Medical Director collaborates with a multidisciplinary team and is actively involved in the management of medical benefits. The collaboration often involves the member’s primary care provider or specialist physician. It is the primary responsibility of the medical director to ensure that the appropriate and most cost-effective quality medical care is provided to members.

You’ll enjoy the flexibility to telecommute* from anywhere within United States as you take on some tough challenges.

Primary Responsibilities:

Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations
Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements
Engage with requesting providers as needed in peer-to-peer discussions
Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
Participate in daily clinical rounds as requested
Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy
Communicate and collaborate with other internal partners
Call coverage rotation

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications: 

M.D or D.O.
Board certification approved by the American Board of Medical Specialties (ABMS)
Active unrestricted license to practice medicine
5+ years of clinical practice experience after completing residency training
Sound understanding of Evidence Based Medicine (EBM)
Solid PC skills, specifically using MS Word, Outlook, and Excel

Preferred Qualifications:  

Experience in utilization and clinical coverage review
Data analysis and interpretation aptitude
Excellent oral, written, and interpersonal communication skills, facilitation skills
Innovative problem-solving skills
Excellent presentation skills for both clinical and non-clinical audiences