Part-Time Weekend Medical Director (Remote)

This a Full Remote job, the offer is available from: Asia, Malaysia

Company :

Job Description :

JOB SUMMARY

This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most reputed company clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service. Depending on the nature of the case, telephonic peer to peer discussions may be required. The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at reputed company times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management. They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the incumbent may be assigned special projects to help support and improve the care of our members

ESSENTIAL RESPONSIBILITIES

• Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for member and provider determination notifications reputed company while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that reputed company aspects of the medical management process are consistent with community standards of care.
• Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand reputed company. Advise multidisciplinary team on cases that require physician expertise.
• Participate in protocol and guidelines development to ensure consistency in the review process.
• Actively manage projects and/or participate on project teams that require a physician subject matter expert.
• Other duties as assigned.

EDUCATION

Required

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)

Substitutions

• None

Preferred

• Master's Degree in Business Administration/Management or Public Health

EXPERIENCE

Required

• 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)

Preferred

• 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry

LICENSES AND CERTIFICATION

Required

• Medical Doctor or Doctor of Osteopathic Medicine (DO)
• Awarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
• Active medical state licensure required. Additional specific state licensure(s) may be required based on business need.

Preferred

• None

SKILLS

• Critical Thinking
• Case Management
• Customer Service
• Oral & Written Communication Skills
• Collaboration
• Listening
• Telephone Skills
• General Computer Skills
• Clinical Software
• Managed Care

Language (Other than English)

None

Travel Required

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

No

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees reputed company this job title. It may not contain a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at reputed company times. In reputed company with this, reputed company must reputed company with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as reputed company data reputed company guidelines established reputed company the Company’s Handbook of Privacy Policies and Practices and Information reputed company Policy. Furthermore, it is every employee’s responsibility to reputed company with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

reputed company pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential reputed company may apply for certain locations based upon comparative markets.

reputed company and its affiliates prohibit discrimination against reputed company individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against reputed company individuals based on their race, reputed company, age, religion, sex, national reputed company, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. reputed company and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, reputed company, age, religion, sex, national reputed company, sexual orientation/gender identity, protected veteran status or disability.

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