Essential Job Duties:
- Participates in and oversees medical review case management, including determination of medical necessity according to payment guidelines and regulations; researches investigational or controversial medical procedures
- Determines utilization, performs coding and medical necessity issues
- Participate in meetings with client or other interested parties to discuss existing and newly developed coverage issues
- Participate in peer review quality oversight of physicians and other health professionals who conduct determinations and perform re-review when necessary and provide feedback to reviewers
- Supervise and manage MAXIMUS physician team members
- Participate in the recruitment, training and oversee members of internal and external contracted clinical personnel
- Directs the development of training materials for clinical staff (nurses, physical therapists and physicians).
- Develop and implement processes resulting in maintaining and improving productivity while maintaining high quality for utilization and medical necessity review
- Participates in quality assurance programs and operational continuous improvement initiatives to monitor quality and performance
- Perform environmental scan to identify emerging clinical issues.
- Contributes clinical expertise for the development of new business
- Performs other duties as may be assigned by management
- Education and Experience:
- Doctor of Medicine or Osteopathy currently licensed in a US State, with Board certification in one of more specialties recognized by the ABMS (American Board of Medical Specialties) or AOBM (American Osteopathic Board of Medicine).
- At least five (5) years, post Board certification, experience in direct patient care, following the completion of a residency program required
- Knowledge of Medicare programs, preferred DME coverage and payment rules
- At least two (2) years' experience in a management role with oversight of quality assurance or medical management functions, including "evidence based medicine" research or application, strongly preferred
- Technology experience with programs, i.e., Microsoft Office (Word and Excel) and ability to research utilizing the internet preferred, including web based portals
- The preferred candidate will have two (2) or more years' experience as a Medical Director for a Medicare Contractor (e.g., Fiscal Intermediary, Carrier, etc.) or health insurance company and intimate knowledge of Medicare coverage and reimbursement policies, and related issues
- Ability to pass stringent credentialing based upon URAC/NCQA type standard
- Demonstrates teamwork and promotes positive company relations
- Excellent organizational, interpersonal, written, and verbal communication skills required
- Ability to work as a team member in a fast-paced, deadline-oriented work environment
- Ability to successfully manage/ and execute multiple complex tasks simultaneously
A committed and diverse workforce is our most important resource.
MAXIMUS is and Affirmative Action/Equal Opportunity Employer.
MAXIMUS provides equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disabled status.
Healthcare Effectiveness Data And Information Set