Utilization Management Medical Director

Local Jobs Cigna in Business Development
  • United States, Nashville, TN 37214 View on Map
  • Post Date: June 18, 2020
  • Apply Before : July 18, 2020
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Job Description

POSITION SCOPE:
Medical Directors in UM will report to the Medical Director Manager over UM and will be a member of the Medical Director UM team. This physician will be responsible for completing UM determinations and assisting with appeals. This physician may also be responsible for assisting in the CM of our customers.

The Medical Directors in UM will work alongside their dyad partners, the MME’s and the UM Clinical Operational team, and will be responsible for performing all key business and clinical initiatives regarding UM and CM.

RESPONSIBILITIES:
The UM Medical Directors to support Cigna’s Medicare Business in Utilization Management and works with the clinical operations UM team in the development of skills related to their job.

Participate in a National Queue for utilization management reviews including Part C prior authorization, inpatient concurrent review, post-acute care authorizations and concurrent reviews. To a lesser extent will also participate in the National Queue for appeals.

Works collaboratively as a consultant to CM operations team to support customers in CM, not limited to, but includes participating in rounds.

The UM Medical Director team facilitates UM consistently and compliantly using benefit plan information, applicable CMS and state regulations, clinical guidelines, emerging codes, new trends and best practice principles.

Preforms all proactive & reactive peer-to-peers for Part C prior authorization, inpatient concurrent review and post-acute prior authorization and concurrent review.

Works to achieve quality outcomes for customers with a focus on service and affordability.

The UM Medical Director team will help improve clinical outcomes through daily interactions with health care professionals using active listening education, excellent communication, and negotiation skills.

Works to achieve 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.

Aware of the Appeal process as appropriate and supports the Appeals Medical Director team when necessary.

UM Medical Directors will be encouraged to achieve personal career growth by creating protected time for associated activities.

Participates in committees representing UM for Cigna’s Medicare Business were appropriate.

In conjunction with the Regional MME and UM Medical Director Manager develops, refines, reviews and acts upon utilization review reporting metrics both national and occasionally at the market level. These metrics should demonstrate operational effectiveness including financial analysis and provider and customer satisfaction analysis.

Collaborates with the Regional MME, UM Medical Director and the Commercial UM Medical Directors to coordinate efforts to improve outcomes and affordability related to UM and it’s interaction with other functional areas.

REQUIRED SKILLS:
Degree in Medicine from an accredited school and is licensed to practice medicine (Doctor of Medicine or Doctor of Osteopathic Medicine).

Current active unrestricted medical license.

Current board certification in an ABMS or AOA recognized specialty.

Minimum of five years of clinical experience is required.

Minimum of five years of experience in medical management, utilization review and case management in a managed care setting.

Previous experience managing physicians, nurses or employees preferred.

Knowledge of managed care products and strategies.

Ability to work within changing business environment and balance patient advocacy with business needs.

Experience with managing multiple projects in a fast-paced matrix environment.

Demonstrated ability to educate colleagues and staff members.

Successful experience and comfort with change management.

Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem solving skills.

Successful ability to assess complex issues, to determine and implement solutions, and resolve problems.

Success in creating and maintaining cooperative, successful relations with diverse internal and external stakeholders.

Demonstrated sensitivity to culturally diverse situations, participants, and customers/members.

About Cigna

Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation.

When you work with Cigna, you’ll enjoy meaningful career experiences that enrich people’s lives while working together to make the world a healthier place. What difference will you make? To see our culture in action, search #TeamCigna on Instagram.

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.

If you require an accommodation based on your physical or mental disability please email: [email protected] Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.

 

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