Medical Director (16011369)
This is a full time Work from Home opportunity for the right candidate. Needs to have an active medical license.
The Medical Director performs medical review and case management activities. The physician provides clinical insight to the organization through peer review, benefit review, consultation and service to internal and external customers. They will serve as a clinical educator and consultant to utilization management, case management, network, contracting, pharmacy, and service operations (claims). This is an entry-level position for physicians interested in a career in health care administration. Great work/life balance schedule is Mon-Fri 8am-5pm with no nights, no weekends, no on-call, and no travel.
- Perform benefit-driven medical necessity reviews for coverage, case management, and claims resolution, using benefit plan information, applicable federal and state regulations, clinical guidelines and best practice principles.
- Works to achieve quality outcomes for members on service and cost.
- Improve clinical outcomes through daily interactions with providers using negotiation, education, and excellent communication skills.
- Balance patient needs with business needs while serving as a member/patient advocate at all times.
- Participate in all levels of the Appeal process as appropriate.
- Participate in coverage guideline development.
- Participate in quality processes such as audits, inter rater reliability actions, and quality projects.
- Serve as a mentor or coach to other Medical Directors and other colleagues in ongoing quality and performance improvement processes.
- Improve provider relations through direct communication, knowledge of appropriate evidence-based clinical information, and the fostering of positive collegial relationships.
- Address customer service issues with mentoring and support from leadership staff.
- Investigate and respond to account questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff.
- Achieve internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions.
- Provide clinical insight and management support to other functional areas and matrix partners as needed or directed.
- Board-certified physician is required family medicine, internal medicine, neurologist or spine surgeon.
- Pharmacy skill set is desired, but not required.
- Experience in medical management, utilization review and case management in a managed care setting is desired, but not required.
- Willing to consider candidates who are looking to transition out of clinical practice into an administrative position.
- Minimum of 5 years of clinical practice experience and/or direct patient care beyond internship, residency, or fellowship training.
- Exhibits ethical and professional behavior.
- Knowledge of managed care products and strategies.
- Computer Competency: Word processing, Spreadsheet, email and Personal Information Management programs are used extensively and competency in them must be possessed or rapidly acquired.
- Must be able to perform research on internet resources.
- Ability to work within changing business environment and balance patient advocacy with business needs.
- Experience with managing multiple projects in a fast paced matrix environment.
- Demonstrated ability to educate colleagues and staff members.
- Successful experience with change management.
- Demonstration of strong and effective teamwork, negotiation, conflict management, decision-making and problem solving skills.
- Successful ability to assess complex issues, to determine and implement their solutions, and to resolve problems.
- Success in carrying out and maintaining cooperative, successful relations with diverse internal and external stakeholders.
- Demonstrated sensitivity to culturally diverse situations, participants and customers.
- Service marketing, sales and business acumen experience a plus.
Unrestricted medical license
US Candidates Only: Qualified applicants will be considered for employment without regard to race, color, religion, national origin, sex, sexual orientation, gender identity, disability, veteran status. If you require a special accommodation, please visit our Careers website or contact us at SeeYourself@cigna.com.
Primary Location: United States-All Cigna Office Locations
Job: Med Mgt–Medical Services
Work at home opportunity (External):Yes
Shift: Day Job
Employee Status: Regular
Job Type: Standard
Job Level: Individual Contributor
Job Posting: Dec 14, 2016, 8:25:57 AM