The Medical Director provides timely expert medical review of medical necessity requests for clinical services that do not meet utilization review criteria and renders a clinical opinion about the medical service under review while located in a state or territory of the United States.
Responsibilities include:
- Provide timely expert medical review of medical necessity requests for clinical services (including durable medical equipment (DME) requests) and render a clinical opinion about the medical service under review, including post-decision reviews.
- Serve as a subject matter expert for medical necessity requests for durable medical equipment (DME).
- Provide timely and collegial peer-to-peer discussions with treating physicians to clarify clinical information and to explain review outcome decisions.
- Provide timely expert medical review of critical needs DME cases and communicate with DME administration for outreach and timely case processing.
- Engage in continued review of guideline subject matter and updates.
- Provide intermittent weekend call coverage of medical necessity requests.
- Document all actions related to clinical review sessions and attest to review qualifications as required.
- Maintain necessary credentials and immediately inform Evernorth of any adverse actions relating to medical licenses and/or board certifications.
- Support the review of Evernorth clinical guidelines.
- Support and communicate Evernorth policies and procedures to the provider community.
- Testify at ALJ Hearings when your cases are being appealed
- Assist with staff educational training and in-service programs and serve as a clinical resource for Evernorth staff.
- Serve as a Subject Matter Expert when Executive Medical Directors and/or Senior Medical Directors are unavailable.
- Participate in all required educational and quality improvement activities and maintain passing scores in all assessments.
- Assist in reviewing case determinations from clients responding to a provider or member complaint.
- Maintain necessary credentials and immediately inform Evernorth of any adverse actions relating to medical licenses and/or board certifications.
- Other duties as assigned.
Minimum Education, Licensure and Professional Certification requirement:
- M.D. or D.O. degree from accredited institution.
- Minimum of five (5) years of clinical practice experience after completion of all graduate medical education training, including residency and fellowship (when applicable)
- Active board certification in Physical Medicine and Rehabilitation; preference for fellowship accredited Pediatric Physical Medicine and Rehabilitation OR Board Certification in General Pediatrics
- Active unrestricted license to practice medicine in a state or territory of the United States as a doctor of medicine or doctor of osteopathic medicine.
- Knowledge of applicable state and federal laws, URAC and NCQA standards, and utilization management
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
For this position, we anticipate offering an annual salary of 196,800 - 328,000 USD / yearly, depending on relevant factors, including experience and geographic location.
This role is also anticipated to be eligible to participate in an annual bonus plan.
We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group.
About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
