Executive Medical Director, DME/IRF

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🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $238.1k - $396.8k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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The Cigna Group

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛡️ Insurance

Healthcare • Insurance

The Cigna Group is a global health services company that provides medical, dental, pharmacy, behavioral and supplemental insurance products and benefits to individuals, families, employers, brokers, providers and Medicare beneficiaries. It offers employer-sponsored group plans, individual and family plans (including Open Enrollment offerings), Medicare, international health insurance covering more than 200 countries, and digital member services through the myCigna platform (including telehealth and claims management). Its products are delivered through operating subsidiaries such as Cigna Health and Life Insurance Company and other regional affiliates.

📋 Description

• Oversee intraday activities of EviCore’s Durable Medical Equipment and Inpatient Rehabilitation Facility management programs and services • Serve as program internal lead for DME clinical guideline and policy management • Work with the Guideline Manager to create EviCore DME guidelines • Maintain and update DME denial rationales • Represent EviCore in Medicare or Medicaid DME and IRF audits and case discussions • Support development of DME clinical pathways with the pathways team • Create quarterly DME IRR quizzes and hold physician debriefs • Assist in case audits assessing Associate Medical Directors’ and Medical Directors’ decision-making accuracy and adherence to EviCore criteria and processes • Hold regular 1:1 meetings with DME/IRF Associate Medical Directors and Medical Directors • Provide weekend coverage for urgent DME and IRF appeals • Testify at ALJ hearings when cases are appealed or the adjudicating Associate Medical Director is unavailable • Provide audit support for DME and IRF cases reviewed during CMS and client audits • Assist with interviewing, onboarding, and training new DME/IRF Associate Medical Directors • Serve as subject matter expert and first point of contact for problematic or escalated case reviews • Respond to urgent, expedited, or escalated DME and IRF cases and P2Ps • Review client case determinations related to provider or member complaints • Respond to notifications and requests to amend incorrect reviews when the original physician reviewer is unavailable • Manage day-to-day clinical activities of the EviCore DME/IRF Program • Collaborate with Clinical Operations, Non-clinical Operations, and Program Operations leadership to optimize program functioning • Supervise and manage DME/IRF Medical Directors and Associate Medical Directors • Support development and maintenance of EviCore policies, procedures, and clinical certification criteria • Coordinate clinical development and education through educational materials and quarterly sessions • Evaluate Medical Directors’ and Associate Medical Directors’ performance • Coach, mentor, and/or clinically supervise designated Medical Directors and Associate Medical Directors • Support review of EviCore clinical guidelines • Support sales and client management teams as clinical representative when requested • Provide expert medical necessity reviews and clinical opinions, including post-decision reviews • Maintain necessary credentials and report adverse actions involving medical licenses or board certifications • Communicate EviCore policies and procedures to the provider community • Participate in required educational and quality improvement activities and maintain passing assessment scores • Perform other duties as assigned

🎯 Requirements

• 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 in Physical Medicine & Rehabilitation • 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 • Two (2) or more years of managed care experience • Familiarity with automated processes and computer applications and systems • Supervisory and/or management experience strongly preferred • Internet connection through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload when working at home

🏖️ Benefits

• Annual bonus eligibility • Long term incentive plan eligibility • Medical benefits • Vision benefits • Dental benefits • Well-being and behavioral health programs • 401(k) • Company-paid life insurance • Tuition reimbursement • Minimum of 18 days of paid time off per year • Paid holidays • Leaves of absence • Remote work arrangement • Cable broadband or fiber optic internet service with at least 10Mbps download/5Mbps upload for home working