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.

• 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.

• Balances customer/member needs with business needs while serving as a customer/member advocate at all times.

• 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.

• Provides clinical insight and management support to other functional areas and matrix partners as needed or directed.

Minimum Requirements:

• Current unrestricted  license to practice medicine within the scope of his or her profession in a US state, territory, Commonwealth of the US or the District of Columbia

• 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**

Preferred Skill Sets:

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

• 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.

• Service marketing, sales, and business acumen experience a plus.

This role is also anticipated to be eligible to participate in an annual bonus and long term incentive plan.

We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group.