Medical Director – Post-Acute Care – Evernorth Home-based Care – Remote

The job profile for this position is Utilization Review Medical Principal, which is a Band 5 Senior Contributor Career Track Role.

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Summary:

The Medical Director provides timely expert medical review of medical necessity requests for clinical services that do not meet utilization review criteria and renders a clinical opinion about the medical service under review while located in a state or territory of the United States.

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Responsibilities include:

• Provide timely expert medical review of medical necessity requests for clinical services (including post-acute care) and render a clinical opinion about the medical service under review, including post-decision reviews.
• Provide timely and collegial peer-to-peer discussions with treating physicians to clarify clinical information and to explain review outcome decisions.
• Document all actions related to clinical review sessions and attest to review qualifications as required.
• Conduct weekly Case Conferences with nursing and social worker teams; discussing every assigned member receiving care in a post-acute care facility, focusing on discharge planning, complex medical care management, quality of care, appropriate level of care, and appropriate length of stay.
• Maintain necessary credentials and immediately inform eviCore of any adverse actions relating to medical licenses and/or board certifications.
• Support the review of eviCore clinical guidelines.
• Support and communicate eviCore policies and procedures to the provider community.
• Testify at ALJ Hearings when your cases are being appealed
• Assist with staff educational training and in-service programs and serve as a clinical resource for eviCore staff.
• Serve as a Subject Matter Expert when Medical Directors and/or Senior Medical Directors are unavailable.
• Amenable to 1 in 4:5 weekend call from home for case review
• Participate in Joint Operating Committee meetings, to include the review and interpretation of data relevant to the client, and other Virtual events with the Provider Engagement Team in your geographic territory.
• Review and document on cases that are appealed and work with the providers proactively to help with accurate case adjudication
• Participate in all required educational and quality improvement activities and maintain passing scores in all assessments.
• Assist in reviewing case determinations from clients responding to a provider or member complaint
• Maintain necessary credentials and immediately inform eviCore of any adverse actions relating to medical licenses and/or board certifications
• Other duties as assigned

Minimum Education, Licensure and Professional Certification requirement: 

• M.D. or D.O. degree from accredited institution.
• Minimum of five (5) years of clinical practice experience after completion of all graduate medical education training, including residency and fellowship (when applicable)
• Active board certification, primary care specialties (Family Medicine, Internal Medicine, Emergency Medicine) or Physical Medicine and Rehabilitation preferred.
• Active unrestricted license to practice medicine in a state or territory of the United States as a utilization review doctor of medicine or doctor of osteopathic medicine.
• Knowledge of applicable state and federal laws, URAC and NCQA standards, and utilization management

FLSA (Exempt or Non-Exempt) : Exempt

Bonus Type: (Indicate which option is applicable) :

☒Corporate Incentive Plan – CIP (Exempt Team Members)

☐Corporate Success Share Plan – SHARE (Non-Exempt Team Members)

☐Department Incentive Plan 

☐Quarterly

☐Monthly

Status: Full time, 1.0 FTE and 5 days/week schedule

Required Skills: Must be able to type 30 WPM, be proficient computer skills and knowledge of Microsoft Office applications

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an annual salary of 203,200 – 338,600 USD / yearly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

Please note that you must meet our posting guidelines to be eligible for consideration. Policy can be reviewed at this link.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

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