Medical Director, Clinical Reviews

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Requirements:

• Current unrestricted license as a medical or osteopathic doctor.
• Board-Certified MD or DO in one of the American Board of Medical Specialties.
• Five years of clinical experience required, preferably in management or utilization management.
• Skills in utilization management activities in accordance with accreditation standards and guidelines.
• Ability to communicate effectively with peers and providers.

Responsibilities:

• Perform clinical reviews of prospective, concurrent, and retrospective coverage requests for in-patient and out-patient services requiring prior authorization and medical necessity review for all lines of business.
• Communicate with providers and facilities to resolve clinical issues and concerns.
• Support the provider inquiry process for peer-to-peer discussions.
• Perform clinical review of expedited and standard appeals for all lines of business.
• Participate in quality and credentialing reviews and assist with administrative duties.