Medical Director (Remote New York)
MD or DO with an active and unencumbered medical license.
Additional licenses in other states may be required, depending on the CareCentrix client payer account rules, which may require multiple state licenses to be held concurrently.
Minimum of 5 years’ experience in an area of relevant clinical practice, and prefer at least 3 years’ experience with supporting utilization management reviews, managed care programs or care delivery networks.
Expertise in the Post-Acute Care field, including current knowledge on best practices, as well as a general knowledge of requirements of regulatory and accreditation standards for payers and health care providers.
As the Medical Director of Post-Acute Care you will have clinical oversight of the Post-Acute Care (PAC) program for CareCentrix, performing the full range of PAC medical necessity reviews utilizing Industry standard criteria’s well as Client’s clinical criteria for Skilled Nursing Facility (SNF), Long Term Acute Hospital (LTACH)/Inpatient Rehabilitation Facility (IRF) as well as Home Health Service, DME and Home Infusion.
Consults with licensed and non-licensed associates on clinical issues related to authorization requests and clinical guidelines clinical criteria
Conducts medical necessity review in adherence with regulatory and compliance turnaround times on cases that may not meet clinical criteria, and issues adverse determinations as needed
Accepts and conducts case discussions as well as peer-to-peer consultations when requested by an ordering health care professional after an adverse determination has been issued, adhering to required timelines for this activity
Participates in CareCentrix Care Coordination, Utilization Management and Quality Improvement committees, and other Performance improvement activities as requested
Provides input into CareCentrix clinical guidelines, criteria and other decision support tools, including evaluations and recommendations on new and emerging technologies, and industry standard treatment protocols relevant to CareCentrix business Interfaces with key positions within CareCentrix including the Chief Medical Officer, Senior Medical Director and executive team members, and serves as a clinical resource for communications with clients and business partners.
Utilizes clinical integrity in all determinations
Collaborates with Health Plan clinical leadership as requested.
Participates in special projects and performs other duties as assigned
Participates in case reviews with the CareCentrix clinical team and provides educational support as needed
Has consultations with practitioners in the field
Travels routinely to facilities where we have Nurse Liaisons for on-site observation, feedback and coaching of CareCentrix clinical team members
Successfully completes and passes Inter-rater reliability testing and random case audits
Achieves Service Level Agreement (SLA) metrics as required by health plan clients
You also can send your resume to .