Medical Director

Overview

This position provides clinical oversight and Utilization management of Post-Acute Care (PAC) facilities and CORE business (i.e. Home Health, DME, Home Infusion Therapy, Sleep, etc.), medically appropriate redirection to lower levels of care, coordination of discharges and post discharge follow up to prevent readmissions. A key part of the role is to work strategically with UM leaders and market engagement to overcome facility barriers to discharge and conduct clinical conversations with facility physicians as needed to impact admissions to PAC facilities and influence PAC length of stay. In this role the Medical Director will perform medical necessity reviews utilizing industry standard criteria, as well as client specific clinical criteria, for Skilled Nursing Facility (SNF), Long Term Acute Hospital (LTACH), Inpatient Rehabilitation Facility (IRF) and CORE functions. The Medical Director will also be responsible for supporting hospital discharge management for up to 90 days post discharge providing education and high-risk member support to the Readmission Program.

• Conducts efficient medical necessity reviews and peer to peer consultations in adherence with regulatory and compliance turnaround times on cases that may not meet clinical criteria, and issues adverse determinations as needed.
• Provides guidance to licensed and non-licensed associates on clinical issues and case reviews related to authorization requests and clinical guidelines criteria.
• Provides education to UM team to support Post Acute Care and CORE needs, discharge planning, length of stay & utilization management and readmission reduction.
• Completes peer to peer discussions as indicated for Core and PAC when medical necessity criteria are not met, to facilitate proactive discharge planning or when facility stay is no longer medically indicated.
• Supports, adds insight and directs take-away actions for ad hoc complex case rounds and collaborates with multidisciplinary team as needed
• Participates in CareCentrix Care Coordination, Utilization Management, Quality Improvement and clinical education activities, as requested.
• Utilizes clinical integrity in all determinations and interactions with internal and external partners.
• Collaborates with Health Plan clinical leadership as requested.
• Interfaces with key positions within CareCentrix including reporting to the VP of Medical Management or Lead Medical Director and interacting with the Chief Medical Officer and executive team members.
• Collaborates with Market Engagement Directors and facility providers in Joint Opportunity Committee activities as requested/needed
• Travels as needed to facilities where we have Nurse Liaisons for onsite observation, feedback and coaching of CareCentrix clinical team members.
• Successfully completes and passes Inter-rater reliability testing and random case audits.
• Achieves Service Level Agreement (SLA) metrics and performance guarantees as required by health plan clients.
• Participates and supports different committees and clinical rounds as necessary or assigned

• MD or DO with an active and unencumbered medical license. Must have active ABIM or ABMS specialty board certification(s).
• Minimum of 5 years’ experience in an area of relevant clinical practice , and prefer at least 3 years’ experience with supporting utilization management reviews, managed care programs or care delivery networks
• Expertise in the Post-Acute Care, HH, DME and sleep fields, including current knowledge on best practices, as well as a general knowledge of requirements of regulatory and accreditation standards for payers and health care providers
• Expertise in Medicaid health plan or UM is preferred
• This position requires excellent written and verbal communication skills.
• Conveys a strong professional image, exhibits interest quality improvement, and projects a positive attitude toward all assigned work.
• Adheres to and participates in Company\'s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.

• Pay Range: $ – $ / year plus corporate bonus incentive.
• Paid Flex Time Off (FTO) , 401K Savings Plan, Paid Parental Leave and more
• Benefits: Medical, Dental, Vision, 401(k) with company match, HSA employer contributions, Dependent Care FSA employer contribution, Paid Time Off, Personal/Sick Time, Paid Parental Leave, and more.
• Award winning culture that keeps our company values at the heart of everything we do: We Care; We Do the Right Thing; We Strive for Excellence; We Think BIG; We Take our Work Seriously, Not Ourselves.

CareCentrix maintains a drug-free workplace

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We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.

CareCentrix accepts applications on an ongoing basis until a candidate is identified.