Medical Director, Durable Medical Equipment - Work from home - Evernorth

JOB SUMMARY

I. Evernorth Business Title: Medical Director, Durable Medical Equipment

Cigna Title: Utilization Review Medical Principal

II. Department Name and Number: Product Clinical Management 2500

III. Reports to: Executive Medical Director, Durable Medical Equipment                               

IV. Summary:

The Medical Director provides timely expert medical review of medical necessity requests for clinical services that do not meet utilization review criteria and renders a clinical opinion about the medical service under review while located in a state or territory of the United States.

Responsibilities include:

• Provide timely expert medical review of medical necessity requests for clinical services (including durable medical equipment (DME) requests) and render a clinical opinion about the medical service under review, including post-decision reviews.
• Serve as a subject matter expert for medical necessity requests for durable medical equipment (DME).
• Provide timely and collegial peer-to-peer discussions with treating physicians to clarify clinical information and to explain review outcome decisions.
• Provide timely expert medical review of critical needs DME cases and communicate with DME administration for outreach and timely case processing.
• Engage in continued review of guideline subject matter and updates.
• Provide intermittent weekend call coverage of medical necessity requests.
• Document all actions related to clinical review sessions and attest to review qualifications as required.
• Maintain necessary credentials and immediately inform Evernorth of any adverse actions relating to medical licenses and/or board certifications.
• Support the review of Evernorth clinical guidelines.
• Support and communicate Evernorth policies and procedures to the provider community.
• Testify at ALJ Hearings when your cases are being appealed
• Assist with staff educational training and in-service programs and serve as a clinical resource for Evernorth staff.
• Serve as a Subject Matter Expert when Executive Medical Directors and/or Senior Medical Directors are unavailable.
• Participate in all required educational and quality improvement activities and maintain passing scores in all assessments.
• Assist in reviewing case determinations from clients responding to a provider or member complaint.
• Maintain necessary credentials and immediately inform Evernorth of any adverse actions relating to medical licenses and/or board certifications.
• Other duties as assigned.

Minimum Education, Licensure and Professional Certification requirement: 

• M.D. or D.O. degree from accredited institution.
• Minimum of five (5) years of clinical practice experience after completion of all graduate medical education training, including residency and fellowship (when applicable)
• Active board certification in Physical Medicine and Rehabilitation; preference for fellowship accredited Pediatric Physical Medicine and Rehabilitation.
• Active unrestricted license to practice medicine in a state or territory …