Medical Director

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

📋 Description

• Conduct benefit-oriented medical necessity assessments for coverage, case management, and claims resolution utilizing benefit plan details, federal and state regulations, clinical guidelines, and best practices.

• Strive to achieve quality outcomes for customers/members with an emphasis on service and cost-effectiveness.

• Enhance clinical outcomes through daily engagement with healthcare professionals using active listening, education, communication, and negotiation skills.

• Balance the needs of customers/members with business objectives while advocating on their behalf.

• Engage in all suitable and permitted levels of the appeal process.

• Contribute to the development of coverage guidelines and the creation and management of medical management projects, initiatives, and committees.

• Take part in audits, inter-rater reliability clinical reviews, and quality improvement projects.

• Mentor or coach Medical Directors and peers in quality and performance enhancement initiatives.

• Strengthen relationships with healthcare professionals through direct communication and providing evidence-based clinical information.

• Utilize current evidence-based guidelines, including innovative treatments, as a peer reviewer for medical and behavioral health conditions, diseases, treatments, and procedures.

• Keep knowledge current through monthly updates on Cigna’s evidence-based coverage policies, mandatory inter-rater reliability testing, continuing medical education, and maintaining board certification.

• Address customer service concerns with guidance and support from leadership.

• Investigate and respond to inquiries from clients and regulatory bodies.

• Meet customer satisfaction and regulatory/accreditation compliance targets through prompt coverage evaluations and quality review decisions.

• Provide clinical insights and management assistance to other functional areas and matrix partners.

⛳️ Requirements

• A current unrestricted medical license in a U.S. state or territory.

• Current board certification (lifetime certification or certification maintained by MOC or other applicable program) in an ABMS or AOA recognized specialty.

• Adherence to ethical and professional standards.

• A minimum of 5 years of clinical practice experience and/or direct patient care beyond residency.

• Proficient in word processing, spreadsheets, email, PowerPoint, and Personal Information Management programs, or the ability to quickly gain proficiency.

• Must not be excluded from participation in any federal healthcare program.

• Must not be listed on CMS’ Preclusion List.

• Reliable cable broadband or fiber optic internet service with a minimum of 10Mbps download and 5Mbps upload speed for remote work.

• Preferred: experience in medical management, utilization review, and case management within a managed care environment.

• Preferred: understanding of managed care products and strategies.

• Preferred: ability to adapt to changing business environments while balancing patient advocacy with organizational needs.

• Preferred: experience managing multiple projects in a dynamic matrix setting.

• Preferred: capability to educate colleagues and staff members.

• Preferred: experience in change management.

• Preferred: strong teamwork, negotiation, conflict resolution, decision-making, and problem-solving skills.

• Preferred: ability to analyze complex issues, determine and implement solutions, and address challenges.

• Preferred: skill in fostering and maintaining collaborative relationships with diverse stakeholders.

• Preferred: awareness of culturally diverse situations, participants, and customers/members.

• Experience in service marketing, sales, and business acumen is a plus.

🏝️ Benefits

• Eligibility for annual bonuses.

• Participation in long-term incentive plans.

• Comprehensive medical benefits.

• Vision insurance.

• Dental coverage.

• Programs for well-being and behavioral health.

• 401(k) retirement plan.

• Company-sponsored life insurance.

• Tuition reimbursement assistance.

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

• Paid holidays.

• Leave of absence options.

• A tobacco-free workplace policy.