Medical Director

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

📋 Description

• Conduct reviews focused on medical necessity for coverage, case management, and claims resolution.

• Utilize benefit plan details, along with federal and state regulations, clinical guidelines, and best practice standards in evaluations.

• Strive to achieve high-quality outcomes for customers/members while emphasizing service and cost efficiency.

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

• Balance the needs of customers/members with business objectives while acting as an advocate for them.

• Engage in all phases of the Appeal process as permitted.

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

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

• Mentor or coach fellow Medical Directors and colleagues on quality and performance enhancement processes.

• Foster improved relationships with healthcare professionals through direct communication and dissemination of evidence-based clinical information.

• Implement current evidence-based guidelines, including innovative treatments, in peer review and clinical decision-making across medical and behavioral health domains.

• Keep knowledge up-to-date through monthly focused updates on Cigna’s evidence-based coverage policies, mandatory inter-rater reliability assessments, continuing medical education, and maintenance of board certification.

• Address customer service concerns with leadership guidance and support.

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

• Ensure prompt coverage review turnaround and quality outcomes to meet customer satisfaction and regulatory/accreditation standards.

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

⛳️ Requirements

• Possession of a current unrestricted medical license in a US state or territory.

• Current board certification (either lifetime or maintained through MOC or another relevant program) in a specialty recognized by ABMS or AOA.

• Demonstration of ethical and professional conduct.

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

• Proficiency in computer applications, including word processing, spreadsheets, email, PowerPoint, and Personal Information Management programs.

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

• Must not appear on CMS’ Preclusion List.

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

• Familiarity with managed care products and strategies is advantageous.

• Ability to navigate a changing business landscape while balancing patient advocacy and business needs is preferred.

• Experience managing multiple projects in a dynamic matrix environment is preferred.

• Proven ability to educate colleagues and staff members is preferred.

• Successful experience and comfort with change management is preferred.

• Skills in teamwork, negotiation, conflict management, decision-making, and problem-solving are preferred.

• Capability to evaluate complex issues, devise and implement solutions, and resolve challenges is preferred.

• Ability to establish and maintain collaborative relationships with diverse internal and external stakeholders is preferred.

• Cultural sensitivity in diverse situations, participants, and customers/members is preferred.

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

🏝️ Benefits

• Eligibility for an annual bonus.

• Participation in a long-term incentive plan.

• Medical insurance coverage.

• Vision insurance coverage.

• Dental insurance coverage.

• Availability of well-being and behavioral health programs.

• Access to a 401(k) plan.

• Company-paid life insurance.

• Tuition reimbursement benefits.

• Minimum of 18 days of paid time off annually.

• Paid holidays.

• Provision for leaves of absence.

• High-speed cable broadband or fiber optic internet service with at least 10Mbps download/5Mbps upload for remote workers.