Akeso Talent Engagement is assisting our partner in the Harrisburg, PA area in their search for a Medical Director to provide clinical oversight to Utilization Management and Medical Necessity Reviews. This is an excellent opportunity for a physician who is looking to transition out of direct patient care OR find an opportunity that allows a better work/life balance with work-from-home benefits, if desired.
Our partner delivers innovative solutions through a family of diversified businesses that is creating a healthier future and lowering health carecosts.
This is an excellent career opportunity for a qualified Physician to support the full spectrum of Medical Management programs in our partner's growing organization. We seek a board-certified MD or DO to provide clinical expertise to Utilization Management/Medical Necessity Reviews, Benefit Determinations, Appeals and Grievances with respect to medical policies, protocols and product designs in accordance with regulatory bodies including NCQA, CMS and the DOH. This Physician participates in the review of medical necessity policies and recommends coverage status based on evidence-based literature. This involves working with external reviewing entities and clinical management and medical policy staff; ensuring that each level of review meets CMS and NCQA compliance; analyzing quality management/claims/utilization/provider contracting statistics; and working with our Pharmacists and Product Development teams to align our utilization goals with members’ needs.
Qualified Physicians will be:
Highly collaborative and able to mentor/advise our clinical management staff and others on rationale for policy stance and process efficiency surrounding several key initiatives including our Quality Management, Prior-Authorization, Concurrent Review, Medical Claim Review, Case management, Disease Management, Pharmacy Management and Health Education programs.
Candidates will be policy-driven and research orientated, with superior communication skills and operational skills in utilization management, QA and credentialing issues in a managed care medical environment.
Must possess a MD or DO degree, current board certification, full and unrestricted Pennsylvania state license, and medical liability insurance or eligibility to obtain.
Five years of clinical experience will ideally include inpatient, outpatient, QA and URAC experience, preferably with 3+ years in managed care or utilization review. Familiarity with Medicare requirements is also needed.