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Encore Medical Principal - Bloomfield, United States - The Cigna Group
Description
Encore Position:
Cigna Retiree Program
Position scope:
Primarily regional with national level case work for Cigna Healthcare (CHC) Cigna, & CareAllies.
Summary description of position:
A Medical Principal performs medical review and case management activities.
The physician provides clinical insight to the organization through peer review, benefit review, consultation, and service to internal and external customers.
He/she will serve as a clinical educator and consultant to utilization management, case management, network, contracting, pharmacy, and service operations (claims).
This is an entry to mid-level position for a physician interested in a career in health care administration. The Medical Director role is a Medical Principal who also manages 2 or more direct reports.Major responsibilities and required results:
Performs benefit-driven medical necessity reviews for coverage, case management, and claims resolution, using benefit plan information, applicable federal and state regulations, clinical guidelines, and best practice principles.
Improves clinical outcomes through daily interactions with health care professionals using active listening, education, and excellent communication and negotiation skills.
Participates in all levels of the Appeal process as appropriate and allowed by applicable regulatory agencies and accreditation organizations
Participates in coverage guideline development, development and maintenance of medical management projects, initiatives and committees.
Participates in quality processes such as audits, inter-rater reliability clinical reviews, and quality projects
Serves as a mentor or coach to other Medical Directors and other colleagues in quality and performance improvement processes.
Improves health care professional relations through direct communication, knowledge of appropriate evidence-based clinical information, and the fostering of positive collegial relationships.
Investigates and responds to client and/or regulatory questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff.
Achieves internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions.
Minimum Requirements:
To qualify:
Must be a Cigna Retiree and meet the Encore Program requirements
Current unrestricted medical license in a US state or territory
Current board certification (lifetime certification or certification maintained by MOC or other applicable program) in an ABMS or AOA recognized specialty
Exhibits ethical and professional behavior.
Minimum of 5 years of clinical practice experience and/or direct patient care beyond residency
Computer Competency:
Word processing, Spreadsheet, Email, PowerPoint and Personal Information Management programs are used extensively and competency in all must be possessed or rapidly acquired.
Must not be excluded from participation in any federal health care program**Must not be included in CMS' Preclusion List**If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we're dedicated to improving the health and vitality of those we serve.
Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients.
Join us in driving growth and improving lives.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
Do not email for an update on your application or to provide your resume as you will not receive a response.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible.
Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment.
These states include:
Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
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