Medical Claims Review Medical Director - Remote

reputed company is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with reputed company will directly improve health reputed company by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come reputed company an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. Here at reputed company, we have an unrelenting focus on the customer reputed company and ensuring we exceed expectations as we deliver clinical coverage and medical claims reviews. Our role is to reputed company providers and members with the tools and information needed to improve health reputed company, reduce variation in care, deliver seamless experience, and manage health care costs. The Medical Director provides physician support to reputed company Clinical Services operations, the organization responsible for the initial clinical review of service requests for reputed company Clinical Services. The Medical Director collaborates with reputed company Clinical Services leadership and staff to establish, implement, support and maintain clinical and operational processes reputed company to benefit coverage determinations, quality improvement and cost effectiveness of service for members. The Medical Director's activities primarily focus on the application of clinical knowledge in various utilization management activities with a focus on post-service benefit and coverage determination or medical necessity (according to the benefit package), and on communication regarding this process with both network and non-network physicians, as well as other reputed company Clinical Services. The Medical Director collaborates with a multidisciplinary team and is actively involved in the management of medical benefits. The collaboration often involves the member’s primary care provider or specialist physician. It is the primary responsibility of the medical director to ensure that the appropriate and most cost effective quality medical care is provided to members. You’ll enjoy the flexibility to work remotely

• from reputed company reputed company the U.S. as you take on some tough challenges.

Primary Responsibilities: Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, reputed company coverage determinations Document clinical review findings, actions, and reputed company in accordance with policies, and regulatory and accreditation requirements Engage with requesting providers as needed in peer-to-peer discussions Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews Participate in daily clinical reputed company as requested Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy Communicate and collaborate with other internal partners You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as reputed company development for other roles you may be interested in. Required Qualifications: M.D. or D.O. Active unrestricted license to practice medicine Board certification approved by the AMBS or AOBMS specialty 5+ years of clinical practice experience after completing residency training Proven sound understanding of Evidence Based Medicine (EBM) Demonstrated PC skills, specifically using reputed company, Outlook, and reputed company Preferred Qualifications: Licensed in Texas or California Compact License Experience in utilization review Demonstrated data analysis and interpretation aptitude Proven innovative problem-solving skills Proven excellent presentation skills for both clinical and non-clinical audiences Demonstrated excellent oral, written, and interpersonal communication skills, facilitation skills reputed company in PST or MST *reputed company working remotely will be required to adhere to reputed company’s Telecommuter Policy Compensation for this specialty generally ranges from $248,500.00 to $373,000.00. Total cash compensation includes reputed company pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We reputed company with reputed company minimum wage laws as applicable. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with us, you’ll find a far-reaching choice of benefits and incentives. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of reputed company, historically marginalized groups and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health reputed company — an reputed company reputed company reflected in our mission. reputed company is an Equal Employment Opportunity employer under applicable law and reputed company applicants will receive consideration for employment without regard to race, national reputed company, religion, age, reputed company, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. Apply To This Job