Executive Medical Director, DME/IRF

This is a fully remote position, open to applicants in United States.

📋 Description

• Manage the intraday operations of EviCore's Durable Medical Equipment and Inpatient Rehabilitation Facility management programs and services.

• Act as the internal program lead for the management of DME clinical guidelines and policies.

• Collaborate with the Guideline Manager to develop EviCore DME guidelines.

• Keep DME denial rationales up to date and maintain them effectively.

• Represent EviCore during audits and case discussions related to Medicare or Medicaid DME and IRF.

• Assist the pathways team in the development of DME clinical pathways.

• Develop quarterly DME IRR quizzes and conduct physician debriefs.

• Support case audits to evaluate the decision-making accuracy of Associate Medical Directors and Medical Directors, ensuring adherence to EviCore criteria and processes.

• Hold regular one-on-one meetings with DME/IRF Associate Medical Directors and Medical Directors.

• Provide weekend coverage for urgent DME and IRF appeals.

• Testify at ALJ hearings when cases are appealed or when the adjudicating Associate Medical Director is unavailable.

• Offer audit support for DME and IRF cases reviewed during CMS and client audits.

• Assist in interviewing, onboarding, and training new DME/IRF Associate Medical Directors.

• Act as a subject matter expert and first contact for challenging or escalated case reviews.

• Address urgent, expedited, or escalated DME and IRF cases and P2Ps.

• Review client case determinations regarding provider or member complaints.

• Respond to notifications and requests for amending incorrect reviews when the original physician reviewer is unavailable.

• Oversee daily clinical activities of the EviCore DME/IRF Program.

• Collaborate with Clinical Operations, Non-clinical Operations, and Program Operations leadership to enhance program efficiency.

• Supervise and manage DME/IRF Medical Directors and Associate Medical Directors.

• Assist in the development and maintenance of EviCore policies, procedures, and clinical certification criteria.

• Coordinate clinical development and education through training materials and quarterly sessions.

• Assess the performance of Medical Directors and Associate Medical Directors.

• Coach, mentor, and/or provide clinical supervision to designated Medical Directors and Associate Medical Directors.

• Contribute to the review of EviCore clinical guidelines.

• Support sales and client management teams as a clinical representative upon request.

• Provide expert reviews on medical necessity and clinical opinions, including post-decision evaluations.

• Maintain necessary credentials and report any adverse actions related to medical licenses or board certifications.

• Communicate EviCore policies and procedures to the provider community.

• Engage in required educational and quality improvement activities while maintaining passing assessment scores.

• Perform additional duties as assigned.

⛳️ Requirements

• M.D. or D.O. degree from an accredited institution.

• At least five (5) years of clinical practice experience after completing all graduate medical education training, including residency and fellowship (if applicable).

• Current board certification in Physical Medicine & Rehabilitation.

• Active, unrestricted medical license to practice in a state or territory of the United States as a physician or doctor of osteopathy.

• Understanding of relevant state and federal laws, URAC and NCQA standards, and utilization management.

• Minimum of two (2) years of experience in managed care.

• Familiarity with automated processes and various computer applications and systems.

• Supervisory and/or management experience is highly preferred.

• An internet connection through a cable broadband or fiber optic service provider with speeds of at least 10Mbps download and 5Mbps upload for remote work.

🏝️ Benefits

• Eligibility for annual bonuses.

• Participation in long-term incentive plans.

• Comprehensive medical benefits.

• Vision and dental benefits.

• Access to well-being and behavioral health programs.

• 401(k) retirement plan.

• Company-paid life insurance.

• Tuition reimbursement opportunities.

• At least 18 days of paid time off annually.

• Paid holidays and leaves of absence.

• Flexible remote work arrangements.

• Requirement of cable broadband or fiber optic internet service with a minimum of 10Mbps download and 5Mbps upload for home working.