SVP Medical Director

Role Overview

• To evaluate medical reports escalated due to deficient information utilizing evidence based criteria;
• To provide leadership within the dedicated team of clinician and claim professionals.
• Participate in client stewardship discussions, claim roundtables, and complex medical escalations.
• Stay current on emerging medical trends, treatment standards, clinical literature, and evidence-based guidelines;
• Support workers’ compensation, disability, FMLA, fitness-for-duty, return-to-work, liability, and safety-sensitive workforce issues.
• Obtain and maintain Medical Director licensure in a few select states, as needed.
• Apply applicable clinical guidelines and medical literature to support defensible recommendations, claim discussions, and treatment-plan clarification.
• Engage treating providers when needed and support appeals, independent medical review considerations, peer review alignment, and clinical quality review.
• Documenting recommendations within templates in Juris and SharePoint using the appropriate format referencing evidence-based criteria within the required time frame.
• Developing and delivering training materials and presentations to meet training needs.
• Interfacing and providing guidance and leadership to the Client dedicated leadership team as well as team leads.

Requirements

• Medical Doctor (M.D.) degree required.
• Ten (10) of related experience required to include one (1) to three (3) years utilization review experience and three (3) years clinical quality control.
• Knowledge of evidence-based guidelines
• Knowledge of ADAA and FMLA
• Knowledge of utilization review procedures
• Knowledge of clinical quality systems and measurements
• Knowledge of resources available regarding regulations and parameters of third party reimbursement, benefit determinations and payments
• Knowledge of statutory requirements of state's jurisdiction/ERISA regulations
• Knowledge about general claim practices.
• Knowledge of pharmacy processes and pharmacy benefit management a plus.
• Understanding of pain management a plus.
• Excellent oral and written communication skills, including presentation skills
• PC literate, including Microsoft Office products
• Analytical and interpretive skills
• Strong organizational skills
• Excellent interpersonal skills
• Proven management/leadership skills
• Ability to create and complete comprehensive, accurate and constructive written reports
• Ability to work in a team environment.

Benefits

• Three medical, and two dental & vision plans to choose from.
• Tuition reimbursement
• 401K plan that matches 50% on every $ you put in up to the first 6% you save.
• 4 weeks PTO your first full year.
• Reasonable accommodations when applicable and appropriate.