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Medical Director DME/HH

Summary:

The Medical Director DME & HH oversees intraday activities of EviCore's Durable Medical Equipment and Home Health management programs and services. Responsibilities include:

• Serve as program internal lead for DME clinical guideline and policy management
  • Work with Guideline Manager to create EviCore DME guidelines
  • Maintain and update DME denial rationales
  • Represent EviCore in audits or case discussions specifically arranged around Medicare or Medicaid policies regarding DME and HH issues/decisions
• Work with pathways team and provide clinical support for development of DME clinical pathways
• Create quarterly DME quiz and hold quarterly debrief with physicians after quiz is completed
• Assist in case audits to assess the accuracy of Associate Medical Directors' & Medical Directors' decision making and adherence to the EviCore criteria and processes
• Hold regular 1:1 meetings (alternating with program chief) with DME/HH associate medical directors/medical directors
• Provide weekend coverage to complete urgent DME & HH appeals that cannot be completed by the on call DME associate medical director/medical director
• Testify at ALJ Hearings when your cases are being appealed or adjudicating Associate Medical Director is unavailable
• Provide audit support for DME & HH cases reviewed during CMS and client audits
• Assist with interviewing, onboarding, and training new DME/HH Associate Medical directors
• Serve as a Subject Matter Expert and first point of contact for Associate Medical Directors who are seeking assistance with problematic case reviews, or escalated cases that deserve immediate review and attention
• Respond to urgent, expedited, or escalated DME and HH cases and P2Ps
• Assist in reviewing case determinations from clients responding to a provider or member complaint
• Assist in responding to notifications and requests to amend incorrect reviews when the physician reviewer who initially reviewed the case is not available
• Manage the day-to-day clinical activities of the EviCore DME/HH Program
• Collaborate with leadership from Clinical Operations, Non-clinical Operations, and Program Operations to support and promote optimal program functioning and identify opportunities for improvement
• Supervise and manage activities of the DME/HH program's Medical Directors and Associate Medical Directors to ensure effective and objective application of clinical guidelines, accurate determination of medical necessity, and efficient processing of clinical case review requests in accordance with legal and contractual obligations
• Support the development and maintenance EviCore policies and procedures and criteria related to clinical certification
• Coordinate the clinical development and education of the DME/IRF program's Medical Directors and Associate Medical Directors through collection/ circulation of educational materials, organization of quarterly educational sessions, and other activities as appropriate
• Evaluate the performance of the DME/HH program's Medical Directors and Associate Medical Directors.
• Serve as a coach, mentor, and/or clinical supervisor for specific Medical Directors and/or Associate Medical Directors
• Support the review of EviCore clinical guidelines
• Support sales and client management teams as clinical representative for designated program when requested by Program Chief
• Provide timely expert medical review of medical necessity requests for clinical services and renders a clinical opinion about the medical service under review, including post-decision reviews, when necessary to support timely completion of clinical cases within the designated program
• Maintain necessary credentials and immediately informs EviCore of any adverse actions relating to medical licenses and/or board certifications
• Support and communicates EviCore policies and procedures to the provider community.
• Participate in all required educational and quality improvement activities and maintain passing scores in all assessments
• 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 & Rehabilitation preferred.
• Active unrestricted license to practice medicine in a state or territory of the United States as a utilization review doctor of medicine or doctor of osteopathic medicine.
• Knowledge of applicable state and federal laws, URAC and NCQA standards, and utilization management

Minimum Experience required (number of years necessary to perform role):

• Two (2) or more years of managed care experience
• Supervisory and/or management experience strongly preferred
• Familiarity with automated processes and computer applications and systems also required

Competencies:

• Ensures Accountability
• Drives Results
• Manages Complexity
• Drives Engagement
• Develops Talent

This role is also anticipated to be eligible to participate in an annual bonus and long term incentive plan.

At The Cigna Group, you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year, paid holidays, and leaves of absence. For more details on our employee benefits programs, click here.

About Evernorth Health Services

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you need a reasonable accommodation to complete the online application process, please email seeyourself@thecignagroup.com for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.

Cigna has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.