Medical Director at 360X Staffing

The Medical Director is responsible for actively participating in the review process of pre-service requests for services, and following guidelines in the approval of those services or in making recommendations for other determinations to the provider/vendor (denial/modification/redirection). Additionally, the role will cooperate with and support the other physician reviewers, nurses, and Medical Directors by knowing all processes and procedures, while working to deliver excellent care cost-effectively based on medical management referral processing guidelines. The Medical Director will be detail-oriented and able to research and successfully evaluate often-complex clinical information to help formulate decisions and communicate with members, providers, and internal users.

Job Details

Prior Authorization. Physician shall

• Understand, promote, and manage the principles of medical management to facilitate the right care for patients at the right time and in the right setting
• As part of a team of medical directors, nurses, and coordinators participate in the pre-service medical necessity review of patient care
• Review prior authorization requests for medical necessity using appropriate clinical guidelines
• Identify high-risk patients and help coordinate care with the Employer’s high-risk team
• From time to time, meet with individual primary care physicians, specialists, and/or provider groups to review best practices for patient care
• Perform prior authorization functions for various Employer campuses, should the need arise in cross coverage, secondary/tertiary review, or medical director decision-making
• Perform retroactive claims review for outpatient and inpatient care, as needed

Provider Relations. Physician shall

• Work with the Employer’s network management team to establish and maintain provider relations
• Be a direct resource to the IPA providers on issues related to UM and other aspects of patient care

Quality/Grievance and Appeals. Physician shall

• Understand the Employer and its affiliates’ internal programs for Q/G&A and may review and respond to G&A and peer review
• Participate in meetings to review, develop, and continually improve internal quality improvement and peer review processes and programs
• Perform verbal counseling to IPA providers after G&A determinations for corrective action plans and follow-ups

Job Requirements

• Doctor of Medicine degree
• Specialty training and/or managed care experience preferred
• Minimum of five years of prior clinical experience required, with at least two years of managed-care or health-plan experience preferred
• Must demonstrate a strong clinical fund of knowledge
• Must have familiarity with the principles of clinical research and have the ability to interpret and apply clinical guidelines and policies
• Strong proficiency in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point) and ability to conduct research over the internet