Medical Director, Prior Authorization

 About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. 

We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.  

JOB SUMMARY:

Seeking a highly skilled and detail oriented Medical Director to join our team. The Medical Director will play a critical role in assessing the quality of clinical services provided to Medicare beneficiaries ensuring compliance with clinical guidelines and regulations while helping to drive improvements in care delivery. After completion of mentored training, daily work includes reviewing and analyzing clinical records, charts and case files to ensure that all clinical practices, treatments and services provided to Medicare beneficiaries meet the highest standards of care and adhere to CMS regulations, policies and procedures. The ideal candidate works closely with multidisciplinary teams to provide insights and feedback on clinical cases and improvement opportunities.
This is a remote position.

ESSENTIAL DUTIES AND RESPONSIBILITIES: 
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.

This is a remote position.

Key Responsibilities:

Case Review: Conduct regular reviews to monitor the appropriateness of care provided to beneficiaries and recommend any necessary interventions or adjustments need to align with CMS National and Local Coverage Determinations (NCD/LCD)

Peer to Peer Prior Authorization discussions: Prepare for and participate in peer-to-peer discussions with providers and suppliers to review clinical documentation, discuss coverage criteria, and address questions related to prior authorization requests.

Training & Education: Assist in the training and development of clinical teams on CMS NCD/LCD guidelines, clinical documentation and compliance.

Clinical Guidance: Provide recommendations for improvements in clinical practices based on findings from record reviews, data analysis, and best practices in the field.

Quality Improvement: Participate in the development and implementation of quality improvement initiatives to enhance care delivery and achieve CMS performance goals.

Documentation:  Maintain accurate and up to date records of all clinical reviews, audits and quality improvement efforts. 

Required Qualifications:

• 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 Anesthesiologists or those with a completed fellowship in pain management are strongly preferred OR be associated with a primary specialty designation that aligns with PMR, neurology, pulmonology, urology, or orthopedics.
• Board certified for at least 3 years;
• Currently hold 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.
• State of Washington license to practice medicine preferred or willingness to obtain.
• Utilization management experience preferred.

Skills:

• Excellent communicatio