Medical Director

TPI Global Solutions

Pittsburgh, PA(remote)

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JOB DETAILS

SKILLS

Administrative Management, Business Administration, Case Management, Centers for Medicare and Medicaid Services (CMS), Clinical Information Systems, Clinical Practices/Protocols, Communication Skills, Computer Skills, Content Management Systems (CMS), Cross-Functional, Customer Escalations, Customer Support/Service, Disease Prevention and Control, Health Insurance, Hospital, Maintain Compliance, Managed Care, National Committee for Quality Assurance (NCQA), Osteopathy, Outpatient Care, Patient Care, Patient Care Authorizations, Presentation/Verbal Skills, Project/Program Management, Public Health, Regulations, Regulatory Compliance, Risk, Standards of Care, Team Player, Telephone Skills, Utilization Management, Utilization Review Accreditation Commission (URAC), Writing Skills

LOCATION

Pittsburgh, PA

POSTED

9 days ago

Job Title: Medical Director – Utilization Management
Location: Remote – Preference EST or nearby Pittsburgh PA,NY,WV
Duration: 6+ Months Contract with possible extension

Position Overview
As part of a physician team, the Medical Director ensures utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of requested treatments or services. Depending on the nature of the case, telephonic peer-to-peer discussions may be required. The Medical Director ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of a multidisciplinary team for case and disease management and advises the team on high-risk and complex cases. Special projects may also be assigned to support and improve member care.

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 determinations, appeals, grievances, and other reviews as assigned.
Compose clear and concise rationales for provider and member determination notifications while adhering to required compliance standards including NCQA, URAC, CMS, DOH, and DOL regulations.
Ensure all 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 rounds.
Advise multidisciplinary teams on cases requiring physician expertise.
Participate in protocol and guideline development to ensure consistency in the review process.
Manage projects and/or participate on project teams requiring physician subject matter expertise.
Preference will be given to candidates with payer-side Utilization Management experience within a health insurance environment. Candidates with only hospital-side UM experience may not meet requirements.

Required Qualifications

Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO).
Minimum 5 years of direct patient care experience in hospital, outpatient, or private practice settings.
Board Certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards.
Active medical state licensure required for PA, NY, or WV.
Expected productivity: 55+ cases completed in an 8-hour day.
Critical thinking skills.
Case management experience.
Customer service skills.
Strong oral and written communication skills.
Collaboration and listening skills.
Telephone skills.
General computer skills.
Experience with clinical software.
Managed care experience.

Preferred Qualifications

Master’s Degree in Business Administration/Management or Public Health.
Minimum 1 year of Medical Management experience within a Health Insurance Plan.
Strong knowledge of the managed care industry.
Experience with MCG or InterQual.

About the Company

TPI Global Solutions

SH Global Solutions is a certified Service Disabled Veteran Owned Small Business (SDVOSB) headquartered in Maryland. Established in 2016 to modernize commercial and government technology to mitigate cybersecurity threats and to secure data centers from increasingly more frequent cyber attacks, we specialize in providing Information Technology (IT) solutions and services to government and commercial organizations. Our core areas of core expertise are focused in:

● Datacenter consolidation/optimization - this includes designing, procuring, and installing turnkey secure, modern infrastructure solutions including scalable and modular systems

● Professional program and project management services for large and complex projects

● In-building wireless solutions to enable 5G technology and connect to the growing Internet of Things (IoT)

Our team is comprised of highly skilled and dedicated professionals, uniquely qualified in cutting-edge technology, and engineering, and in the rapid deployment and implementation of new technologies. Our CEO is a retired United States Air Force Colonel and entrepreneur with over 25 years supporting the DOD, US Government agencies, and NATO worldwide.

COMPANY SIZE

1 to 9 employees

INDUSTRY

Computer/IT Services

FOUNDED

2016

WEBSITE

https://www.shglobalsolutions.com