Executive Medical Director, DME/IRF

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

📋 Description

• Oversee the daily operations of EviCore’s Durable Medical Equipment and Inpatient Rehabilitation Facility management programs and services.

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

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

• Maintain and periodically update DME denial rationales.

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

• Assist in the creation of DME clinical pathways alongside the pathways team.

• Develop quarterly DME IRR quizzes and conduct quarterly debriefs for physicians.

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

• Conduct 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 during CMS and client audits.

• Assist with the interviewing, onboarding, and training of new DME/IRF Associate Medical Directors.

• Serve as a subject matter expert and initial contact for complex or escalated case reviews.

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

• Review case determinations related to provider or member complaints.

• Respond to notifications and requests for amendments to incorrect reviews.

• Oversee the daily clinical operations of the EviCore DME/IRF program.

• Collaborate with leadership from Clinical Operations, Non-clinical Operations, and Program Operations.

• Supervise and manage Medical Directors and Associate Medical Directors.

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

• Coordinate clinical development and education through materials, quarterly educational sessions, and related activities.

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

• Coach, mentor, and/or clinically supervise Medical Directors and Associate Medical Directors.

• Support the review of EviCore clinical guidelines.

• Act as a clinical representative to support sales and client management teams upon request.

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

• Maintain required 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 and maintain satisfactory assessment scores.

• Perform other assigned duties.

⛳️ Requirements

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

• A minimum of five (5) years of clinical practice experience following the completion of all graduate medical education training, including residency and fellowship (if applicable).

• Active board certification in Physical Medicine & Rehabilitation.

• An active and unrestricted license to practice medicine in a state or territory of the United States as a doctor of medicine or doctor of osteopathic medicine for utilization review.

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

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

• Proficiency with automated processes and computer applications and systems.

• Supervisory and/or management experience is strongly preferred.

• Access to an internet connection through a cable broadband or fiber optic provider with minimum speeds of 10Mbps download and 5Mbps upload when working from home.

🏝️ Benefits

• Eligibility for an annual bonus.

• Participation in a long-term incentive plan.

• Comprehensive medical, vision, and dental benefits.

• Access to well-being and behavioral health programs.

• 401(k) plan.

• Company-paid life insurance.

• Tuition reimbursement.

• A minimum of 18 days of paid time off annually.

• Paid holidays.

• Leaves of absence.

• Opportunity for remote work from home.

• Requirement for cable broadband or fiber optic internet with minimum speeds of 10Mbps download and 5Mbps upload.