Sr. Medical Director

October 17, 2020
Newtown Square, PA
Job Type


JOB SUMMARY: This position tasks the incumbent with the regular identification and resolution of compliance and utilization issues through the application of appropriate clinical judgment and regulatory guidance
1. Review and analyze medical records and supporting documentation in order to ensure adherence to clinical standards of practice and applicable governmental or private policies and guidelines relating to medical necessity and appropriateness of services.
2. Independently manage and resolve all case reviews as assigned, including complex cases seeking regular consultation from medical director as appropriate.
3. Effectively summarize key clinical facts of each case and prepare written justification for medical necessity decisions.
4. Ensure established quality and regulatory standards for accuracy and timeliness of review are continuously met.
5. Consistently meet individual productivity levels for assigned tasks, based on expected availability for review activities.
6. May perform appeals considerations when deemed necessary by senior management
7. Collaborate, coordinate, and communicate across disciplines and departments.
8. Ensure compliance with HIPAA regulations and requirements.
9. Demonstrate Company's Core Competencies and values held within.
10. Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role.
11. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.
This job works independently with minimal supervision to complete the job responsibilities. Work is often varied and complex and involves a great deal of research. More complex issues are referred to higher levels. The incumbent follows established procedures and uses knowledge of the Company's general business principles, industry dynamics, market trends, and specific operational details when performing all aspects of the job. This job requires creativity and problem solving skills to successfully complete tasks assigned. The incumbent has regular contact with all levels of internal and external resources.
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