Medical Director will complete assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients; governmental (Medicare/Medicaid) programs and individual client requested coverage determinations or appeals when appropriate
Makes clinical determinations in accordance with medical necessity and criteria
Performs scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to requesting prescribers
Follow all internal procedures, job aids, and HIPPA guidelines to protect patient privacy and data security
Support the Department’s responsibilities to provide peer-to-peer phone call support to physicians/prescribers who call the company with specific and general questions about our clinical programs, communications and utilization review decisions
Communicates effectively and confidently with members to promote positive health outcomes
Actively participates in the development of utilization management (PA) criteria and clinical policy revisions/reviews
Ability to work in a fast-paced environment with shifting priorities
Weekend on-call responsibilities (shared rotating call)
Attention to detail and commitment to delivering high-quality work

Must be a graduate of an accredited Medical School and Residency Program
Active Texas medical license, required
No history of disciplinary actions on Medical License
Minimum 5 years history of clinical practice with direct patient care
Specialty-Internal Medicine
Board certified by appropriate Medical Board (DO, MD)
Be able to satisfy rotating weekend call schedule with another Medical Director
Possess an unrestricted active license to practice medicine in a State, Territory, Commonwealth of the United States, or the District of Columbia
Required annual Continuing Medical Education (CME) up to date and must remain current in medical and management areas during employment
Demonstrated experience in clinical outcomes, working knowledge of medical statistics, regulatory agencies, and analytic programs
Ability to work with virtual teams of pharmacists
Time management skills to meet organizational goals
Knowledge of PBM environment, quality improvement and UM practices in a managed care environment
Knowledge of and appreciation for requirements of regulatory and accreditation agencies
Able to manage multiple priorities and deadlines
Excellent verbal, written, interpersonal and presentation skills
Strong knowledge of clinical medicine, health care delivery and the ability to acquire new scientific and medical knowledge
Proficiency with Microsoft Office applications. (e.g., MS Word, Excel, and PowerPoint minimum)

Medical Director – Texas Licensed

Key skills