Medical Director Health Services - Delaware, OH, United States - Cigna Health and Life Insurance Company

Cigna Health and Life Insurance Company Delaware, OH, United States

3 weeks ago

Description

Primarily regional with national level case work for Cigna Healthcare (CHC) Cigna, & CareAllies.
Market and Regional level case work for Cigna Medicare.
A Medical Principal performs medical review and case management activities.

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.

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.

Works to achieve quality outcomes for customers/members with a focus on service and cost

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.

Addresses customer service issues with mentoring and support from leadership staff.

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.

Current unrestricted medical license in a US state or territory

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** Experience in medical management, utilization review and case management in a managed care setting.

Experience with managing multiple projects in a fast-paced matrix environment.
Demonstrated ability to educate colleagues and staff members.
Fluency in Spanish (Cigna Medicare) or other languages
Primarily regional with national level case work for Cigna Healthcare (CHC) Cigna, & CareAllies.
Market and Regional level case work for Cigna Medicare.
A Medical Principal performs medical review and case management activities.