Job Openings >> Medical Director - (In Brentwood, TN)
Medical Director - (In Brentwood, TN)
Summary
Title:Medical Director - (In Brentwood, TN)
ID:1042
Department:Utilization Management
Description
Overview:
This is a full time position working in our Brentwood, Tennessee office.  The incumbent will perform utilization review for medical necessity determinations for home health care benefits and will work with nursing and therapy reviewers in making determinations. The Medical Director performs case review and peer to peer consultation, provides consultative services to the UM review staff, oversees selection of education for providers, and provides input into the Utilization Management and Quality Improvement programs when requested, This position interfaces with the internal staff, network providers, and ordering physicians as required.

PRIMARY RESPONSIBILITIES
  • Conducts medical necessity review on authorization requests for home health care benefits and issues adverse determinations as needed.
  • Conducts peer-to-peer consultations when requested by an ordering physician, adhering to required timelines.
  • Consults with licensed reviewers on clinical issues related to authorization requests for home care benefits.
  • Participates in the Utilization Management and Quality Improvement committees, and other related activities, as requested. 
  • Participates in special projects and performs other duties as assigned.
 
Responsibilities:

ATTRIBUTES/QUALIFICATIONS

This position requires excellent written, verbal and computer communication skills, with the ability to interface effectively with all levels of staff, including ordering physicians, internal and external clinical review teams, and high level executive leadership representatives. This position requires adaptability and ability to prioritize work in a fast paced environment to assure compliance with regulatory and accrediting agency requirements. This position requires knowledge of utilization management principles and regulatory and accreditation standards of utilization review. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

CORE REQUIREMENTS

• Abides by and demonstrates the company Mission – Vision – Values through both behavior and job performance on a day-to-day basis.
• Conveys a strong professional image, exhibits interest and a positive attitude towards all assigned work.
• Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.
• Reviews and adheres to all company policies, procedures, and the Employee Handbook.

PHYSICAL REQUIREMENTS

• Must be able to remain in a stationary position 90% of the time.
• Constantly operates a computer and other office equipment
• Frequently communicates via phone, email, and Skype. Must be able to exchange accurate information in these situations. 
• Occasionally lift items weighing up to 10 pounds.

QUALIFICATIONS:
The Medical Director must be an MD or DO with appropriate current and unexpired specialty board certification in Physical Medicine and Rehabilitation, or other field beneficial to Home Health reviews.  He/she must have an active and unencumbered medical license in the states specific to the client payer account rules, which may require multiple state licenses to be held concurrently. A minimum of 3 years’ experience in clinical practice and preferably at least 2 years’ experience with managed care programs or care delivery networks is required. The Medical Director should have expertise in specific clinical fields, including current knowledge of best practices and new technology, as well as a general knowledge of requirements of regulatory and accreditation standards for payers and health care providers. He/she should have understanding of current clinical guidelines and their application to case review. Prior experience using evidence-based clinical guidelines (e.g., Milliman, InterQual) is preferred.
 
 
 
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