Medical Director

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

📋 Description

• Conduct benefit-focused medical necessity assessments for coverage, case management, and claims resolution.

• Utilize benefit plan details, federal and state regulations, clinical guidelines, and best-practice methods.

• Attain quality results for customers and members while prioritizing service and cost efficiency.

• Enhance clinical outcomes through engagement with health care professionals, emphasizing listening, education, communication, and negotiation.

• Balance the needs of customers/members with business objectives while advocating for their interests.

• Engage in all relevant levels of the appeal process.

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

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

• Provide mentorship or coaching to Medical Directors and colleagues focused on quality and performance enhancement.

• Strengthen healthcare professional relationships through direct communication and evidence-based clinical data.

• Apply evidence-based guidelines, including innovative treatments, for peer reviews across medical and behavioral health conditions.

• Stay informed through monthly updates to Cigna coverage policies, inter-rater reliability testing, continuing medical education, and maintenance of board certification.

• Address customer service challenges with support from leadership.

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

• Facilitate timely coverage evaluations and quality results to ensure regulatory and accreditation compliance.

• Offer clinical insights and management support to functional areas and matrix partners.

⛳️ Requirements

• Active unrestricted medical license in a US state or territory.

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

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

• Ethical and professional conduct.

• Proficiency in word processing, spreadsheets, email, PowerPoint, and personal information management software.

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

• Must not appear on CMS’ Preclusion List.

• If working remotely, must have an internet connection via cable broadband or fiber optic service with a minimum of 10 Mbps download and 5 Mbps upload speed.

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

• Preferred: understanding of managed care products and strategies.

• Preferred: experience managing several projects in a fast-paced matrix environment.

• Preferred: ability to educate colleagues and staff.

• Preferred: experience in change management.

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

• Preferred: capability to assess complex issues, identify and implement solutions, and resolve challenges.

• Preferred: experience in maintaining relationships with diverse stakeholders.

• Preferred: sensitivity to culturally diverse situations.

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

🏝️ Benefits

• Eligibility for annual bonuses.

• Participation in long-term incentive plans.

• Medical coverage.

• Vision coverage.

• Dental coverage.

• Access to well-being and behavioral health programs.

• 401(k) retirement plan.

• Company-paid life insurance.

• Tuition reimbursement programs.

• A minimum of 18 days of paid time off each year.

• Paid holidays.

• Leaves of absence.