Physical Health Medical Director

Become a part of our caring community

=========================================

The Medical Director is responsible for Medicaid care strategy and/or operations. The Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.Responsibilities:

* Use clinical training, professional experience, and sound medical judgment to determine whether requested services, level of care, or site of service should be authorized. * Make determinations in accordance with regulatory and compliance requirements and with support from approved resources, including national clinical guidelines, state Medicaid policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other established sources. * Develop and maintain a working knowledge of Medicaid requirements and apply that knowledge effectively in daily work within the assigned cluster. * Perform computer-based reviews of moderately complex to highly complex clinical cases from both outpatient and inpatient settings. * Review all submitted clinical documentation and supporting records to determine medical necessity and appropriateness of care. * Prioritize daily review work to meet operational expectations and turnaround requirements. * Communicate determinations and rationale to internal associates in a timely and professional manner. * Participate in care management-related activities, as appropriate. * Conduct peer-to-peer discussions with external physicians by phone to obtain additional clinical information and discuss medical necessity determinations. * Use effective communication and conflict resolution skills in peer-to-peer conversations, particularly in cases involving disagreement or escalated review. * Collaborate with contracted physicians, physician groups, facilities, and community organizations in support of regional market priorities. *