Medical Director, MSK Surgery

Your Future Evolves Here

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.

Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.

Join Evolent for the mission. Stay for the culture.

What You’ll Be Doing:

The Medical Director for MSK Surgery is a key member of the Medical leadership team, providing timely medical review of service requests. Oversees the Surgery Field Medical Directors and interacts with leadership and management staff as well as health plan members and staff whenever a physician`s input is needed or required. Responsible for clinical audits for quality and education regarding the results and monitoring for improvement. Responsible for coordinating education and findings with matrixed Physician Business Manager.

• Provides medical direction to the support services review process. Responsible for the quality of utilization review determinations, including appeals.
• Provides input into audit processes including development of questions.
• Reviews statistical sample of cases for Field Medical Director audits and makes recommendations into the types of cases to review.
• Responsible to assist with all types of audits including Interrater, Customer, Clinical quality, and/or confirmation of process changes.
• Holds Field Medical Director forums for education and question/issue resolution on a scheduled basis.
• In conjunction with other leaders, measures Field Medical Director productivity, quality, and telephone statistics
• In close partnership with Physician Business Managers, provides coaching and guidance. 
• Assists with new hire process of Field Medical Directors. 
• Attends training classes as needed for new hires to educate and train on Utilization management system and Field Medical Director process, standards and resources.
• Acts as assigned mentor as needed for new hires and completes new hire case assessment working on any defined areas of opportunity.
• Assists with Hot Topic identification and content for Field Medical Directors.
• Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request by phone or fax.
• Assists with provider standards and expedited appeals.
• Actively participates in identifying new concepts/projects with projected ROI impacts.
• On a requested basis, reviews appeal cases and/or attends hearings for discussion of utilization management decisions.
• Strong partnership with Physician Business Managers to support the overall success of Field Medical Directors.
• May function as Medical Director for select health plans or regions, assuming overall accountability for utilization management while working in conjunction with the SVP, CCO and/or CMO.
• Additional duties as assigned

Qualifications:

• Graduate of recognized medical degree program
• Minimum of five (5+) years’ experience in the practice of Orthopedic Spine Surgery is preferred.
• Administrative Medical Experience- Utilization Management, Leadership Role or equivalent (2+) years
• One or more current, unrestricted state licenses
• Obtaining and maintaining medical licenses in required states per business need
• Active Board Certification in Orthopedic Spine Surgery or Active Board Certification in Orthopedic Surgery with expertise in Spine Surgery is required.
• Strong clinical, management, communication, and organizational skills
• Energetic and curious with a passion for quality and value in health care
• Computer Proficiency
• Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an “excluded person” by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare.
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