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Medical Director

TekWissen LLC

NULL, NULL(remote)

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JOB DETAILS
SALARY
$178.57–$232.14
SKILLS
Administrative Management, Business Administration, Case Management, 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, Diversity, 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, Telephone Skills, Utilization Management, Utilization Review Accreditation Commission (URAC), Workforce Management, Writing Skills
LOCATION
NULL, NULL(remote)
POSTED
5 days ago
Overview:
TekWissen is a global workforce management provider headquartered in Ann Arbor, Michigan that offers strategic talent solutions to our clients world-wide. Our client is a health and wellness organization located in Pittsburgh and operates health insurance plans in Pennsylvania, Delaware, and West Virginia.
Job Title: Medical Director-CW
Location: Remote
Duration: 5 Months
Job Type: Temporary Assignment
Work Type: Remote
Shift: M-F : 9AM-5PM
Job Description:
  • This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards.
  • The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service.
  • Depending on the nature of the case, telephonic peer to peer discussions may be required.
  • The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times.
  • In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management.
  • They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure.
  • Additionally, the incumbent may be assigned special projects to help support and improve the care of our members.
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 determination of cases, review of appeals and grievances, and other reviews as assigned.
  • Compose clear and concise rationales for members and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.).
  • Ensure that 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 team on cases that require physician expertise.
  • Participate in protocol and guidelines development to ensure consistency in the review process.
  • Actively manage projects and/or participate on project teams that require a physician subject matter expert.
  • Other duties as assigned.
Required Qualifications:
  • Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
  • 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
  • Medical Doctor or Doctor of Osteopathic Medicine (DO)
  • Awarded Board Certification at least once in 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.
  • Critical Thinking
  • Case Management
  • Customer Service
  • Oral & Written Communication Skills
  • Collaboration
  • Listening
  • Telephone Skills
  • General Computer Skills
  • Clinical Software
  • Managed Care
Preferred Qualifications:
  • Master's Degree in Business Administration/Management or Public Health
  • 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry
  • Experience with MCG or InterQual
TekWissen Group is an equal opportunity employer supporting workforce diversity.

About the Company

T

TekWissen LLC

WE THE TEKWISSEN PEOPLE

TekWissen offers you a broader portfolio of services, industry-leading solutions, and the meaningful innovations that give you greater flexibility and speed to respond to market dynamics, reduced costs and risk to improve enterprise performance, and increased productivity to enable growth.

To keep pace with global market demands, TekWissen keeps its finger on the pulse of change. Our organized approach to guiding a project from its inception to closure. Managing projects is becoming more and more important as we enter the digital era. To cope with the pace that this transition demands, a method is required to manage projects so they can yield quality work, while incorporating efficient use of time and resources.

Project involves identifying which quality standards are relevant to the project and determining how to satisfy them.

It is important to perform quality planning during the Planning Process and should be done alongside the other project planning processes because changes in the quality will likely require changes in the other planning processes, or the desired product quality may require a detailed risk analysis of an identified problem. It is important to remember that quality should be planned, designed, then built in, not added on after the fact.

Capabilities and accomplishments in one TekWissen business enhance the opportunity for success in the others. Put simply, TekWissen's unique combination of attributes promotes success.



COMPANY SIZE
100 to 499 employees
INDUSTRY
Computer/IT Services
FOUNDED
2009
WEBSITE
http://www.tekwissen.com/

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