Medical Director – Prior Authorization

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

📋 Description

• We are looking for a highly experienced and detail-oriented Medical Director to become a part of our team.

• The Medical Director will be essential in evaluating the quality of clinical services offered to Medicare beneficiaries, ensuring adherence to clinical guidelines and regulations while fostering enhancements in care delivery.

• Following the completion of a mentored training program, daily responsibilities will include reviewing and analyzing clinical records, charts, and case files to ensure that all clinical practices, treatments, and services provided to Medicare beneficiaries uphold the highest standards of care and comply with CMS regulations, policies, and procedures.

• Conduct regular evaluations to oversee the appropriateness of care provided to beneficiaries and recommend any necessary interventions or adjustments to align with CMS National and Local Coverage Determinations (NCD/LCD).

• Prepare for and engage in peer-to-peer discussions with providers and suppliers to review clinical documentation, discuss coverage criteria, and address inquiries related to prior authorization requests.

• Support the training and development of clinical teams concerning CMS NCD/LCD guidelines, clinical documentation, and compliance.

• Offer recommendations for enhancements in clinical practices based on insights from record reviews, data analysis, and industry best practices.

• Take part in the development and execution of quality improvement initiatives to boost care delivery and meet CMS performance objectives.

• Keep precise and current records of all clinical reviews, audits, and quality improvement activities.

⛳️ Requirements

• Must be a board-certified clinician, including a Doctor of Medicine or a Doctor of Osteopathy identified by an individual NPI in a specialty recognized by the American Board of Medical Specialties.

• Preference for Anesthesiologists or those who have completed a fellowship in pain management, or those associated with a primary specialty designation that aligns with PMR, neurology, pulmonology, urology, or orthopedics.

• Must be board certified for a minimum of 3 years; currently possess an active, valid, and unrestricted license to practice medicine in at least one U.S. state, territory, or the District of Columbia.

• Must not be excluded from participating in Medicare, Medicaid, or the Children’s Health Insurance Program.

• A license to practice medicine in the State of Washington is preferred or a willingness to obtain one.

• Prior experience in utilization management is preferred.

• Excellent verbal and written communication skills with the ability to collaborate effectively with diverse healthcare teams.

• Familiarity with electronic health records (EHR) and documentation and coding practices (ICD-10, CPT).

• Knowledge of CMS regulations and Medicare requirements.

• Strong attention to detail and organizational skills to manage multiple tasks and priorities.

• Ability to thrive in a fast-paced, deadline-driven environment.

🏝️ Benefits

• Enjoy a quality of life with a remote, predictable, full-time schedule.

• Comprehensive training and educational programs available.

• Opportunities for career advancement within the organization.

• Medical, Dental, and Vision coverage provided.

• 401K plan available.

• Paid time off and holidays.

• Long-term disability insurance offered.

• Life insurance coverage included.

• Allowance for CME and/or license renewals.