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. 

Your Schedule:

Training & Onboarding (First 2–3 Weeks)
Training will occur Monday–Friday from 8:00 AM to 5:00 PM CT and will include onboarding, shadowing, workflow education, and hands-on case review training. 

After Completion of Training:
Following successful completion of training, team members will transition to a production schedule of Monday–Friday, 8:00 AM to 5:00 PM PT, as the current business operations are aligned to the Pacific Time Zone.

Each shift will be 9 hours in length, which includes one hour of dedicated break time. Specific schedules may be adjusted based on operational needs

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 communication skills (both verbal and written) 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 work in a fast paced, deadline driven environment

Note:

Primarily remote with occasional on-site requirements.

Occasional travel may be required for team meetings and onsite reviews.

KEYWORDS: Physician; MD; DO; non-clinical careers; Physician Advisor; Medical Director; Prior Authorizations; Utilization Management; Utilization Review; Case Management; UR; UM; remote; work from home; anesthesiology; pmr, neurology, pulmonary, urology, orthopedics; board certified

We Offer: 

• Quality of life with a remote predictable, full-time schedule 
• Comprehensive training and education program 
• Opportunities for career growth within the organization 
• Salary plus bonus opportunities
• Medical, Dental, Vision coverage, 401K 
• Holidays, paid time off, long-term disability insurance, and life insurance 
• Allowance for CME and/or license renewals  

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.