Note: The job is a remote job and is open to candidates in USA. Evolent partners with health plans and providers to achieve better outcomes for people with complex health conditions. As a Field Medical Director, you will provide clinically sound medical reviews for cardiology-related service requests and collaborate with various healthcare professionals to support better health outcomes across member populations.
Responsibilities
- Serve as the specialty-match reviewer for diagnostic cardiology cases that do not initially meet applicable medical necessity guidelines, as well as other requests when providers, clients, or state regulations require specialty reviews to be completed by a cardiology subject matter expert
- Review all cases in which clinical determinations cannot be made by Initial Clinical Reviewers, ensuring appropriate use of evidence-based cardiology guidelines and regulatory standards
- Provide clear, evidence-based clinical rationale for standard and expedited appeals
- Conduct peer-to-peer discussions with requesting physicians or ordering providers, when available, within regulatory timeframes via phone
- Utilize medical and clinical review guidelines and parameters to ensure consistency in physician review processes and appropriate utilization, in alignment with SBU policies and procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) standards
- Assist and act as a clinical resource to Field Medical Directors and Initial Clinical Reviewers to discuss cases, address complex review scenarios, and support problem resolution
- Ensure all communications with medical office staff and/or physician providers are documented accurately and in a timely manner
- Participate in ongoing training initiatives, including inter-rater reliability programs, to promote quality, consistency, and compliance
- Assist the Senior Medical Director, as requested, with research activities and questions related to utilization management processes, guideline interpretation, and system or operational support
- On a requested basis, review appeal cases and/or attend hearings to support utilization management determinations
- On a requested basis, function as Medical Director for select health plans or regions, assuming overall accountability for utilization management activities in collaboration with the Senior Medical Director
Skills
- DO, MD, or MBBS degree from an accredited institution
- Current Board Certification in Emergency Medicine or Internal Medicine by an American Certifying Board
- Current, unrestricted medical license in one or more U.S. states
- Current Unrestricted Medical License in Home State
- Demonstrated strong knowledge of diagnostic cardiology, including evaluation and management of cardiovascular conditions, and the appropriate use of cardiac imaging modalities such as echocardiography, nuclear cardiology, cardiac CT, and cardiac MRI to support evidence-based medical necessity determinations
- Five (5) years of post-residency clinical experience
- Strong verbal and written communication skills, including the ability to effectively engage in peer-to-peer discussions with treating providers
- Proficient computer skills and experience working with clinical review and documentation systems
- Active clinical practice experience within the past 18 months
- Familiarity with utilization management principles and procedures within managed care organizations, including experience with cost-benefit analysis, quality assurance, and continuous quality improvement processes
Benefits
- Comprehensive benefits
- Health insurance benefits
Company Overview
Company H1B Sponsorship