Executive Medical Director, DME/IRF

🔥 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

Founded 1982

🏥 Healthcare

⚕️ Healthcare Insurance

💊 Pharmaceuticals

Healthcare • Healthcare Insurance • Pharmaceuticals

The Cigna Group is a global health company committed to improving the health and vitality of its clients, customers, and patients. With its two divisions, Cigna Healthcare and Evernorth Health Services, the company focuses on enhancing quality of life through healthcare services and pharmacy benefits management. The Cigna Group is dedicated to ethical practices in healthcare and artificial intelligence, and strives to create positive change in the healthcare system. It also emphasizes its Environmental, Social, and Governance (ESG) responsibilities, aiming to impact health equity and foster innovation in healthcare delivery.

📋 Description

• Oversee intraday activities of EviCore’s Durable Medical Equipment and Inpatient Rehabilitation Facility management programs and services • Serve as 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 quarterly physician debriefs • Assist in case audits assessing Associate Medical Directors’ and Medical Directors’ decision-making accuracy and adherence to 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 case determinations related to provider or member complaints • Respond to notifications and requests to amend incorrect reviews • Manage day-to-day clinical activities of the EviCore DME/IRF program • Collaborate with Clinical Operations, Non-clinical Operations, and Program Operations leadership • Supervise and manage Medical Directors and Associate Medical Directors • Support development and maintenance of EviCore policies, procedures, and clinical certification criteria • Coordinate clinical development and education through materials, quarterly educational sessions, and related activities • Evaluate Medical Directors’ and Associate Medical Directors’ performance • Coach, mentor, and/or clinically supervise 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 required credentials and report adverse actions relating to 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, vision, and 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 from home • Cable broadband or fiber optic internet requirement with minimum 10Mbps download/5Mbps upload