JOB SUMMARY
eviCore Business Title: Medical Director, Post-Acute Care
Cigna Title: Utilization Review Medical Principal
II. Department Name and Number: Product Clinical Management 2500
III. Reports to: 0045 Executive Medical Director, PAC or Program Chief, PAC/DME/Sleep Services
Summary:
The Medical Director (MD) 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.
This role will entail working 10 hours every Monday and Friday and alternating weekends 10 hour daily (Saturday and Sunday shifts). This role will also provide coverage for other Medical Directors when on PTO as necessary.
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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.
Participate in rounds as necessary when providing coverage for other Medical Directors.
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.
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) 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
Competencies:
Decision Quality
Persuades
Interpersonal Savvy
Manages Conflict
Self-Development
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 : Part Time .75 FTE and 3 days/week schedule (10 hour days)
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 207,800 - 346,300 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.
At The Cigna Group, 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), 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, click here (https://jobs.thecignagroup.com/us/en/benefits) .
About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.
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.
If you need a reasonable accommodation to complete the online application process, please email seeyourself@thecignagroup.com for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
