Medical Director - Post Acute Care (Remote)

As the Medical Director - Post Acute Care you will provide clinical oversight for one or more CareCentrix markets including Utilization Management reviews of Post-Acute Care (PAC) stay requests, medically appropriate steerage to home, coordination of discharges and post discharge follow up to prevent readmissions. A key part of the role is to work strategically with UM leaders and market engagement directors to overcome facility barriers to discharge. Peer-to-Peer conversations with hospital physicians either pre or post denials, as needed to impact admissions to PAC facilities. Clinical rounds with nurse teams to support PAC length of stay and be available to speak to Appeals in client meetings. In this role, the Medical Director will perform medical necessity reviews utilizing industry standard criteria such as Interqual or MCG and CMS. The primary work will involve PAC facility management including: Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF) and Long Term Acute Care Hospital (LTCH). The Medical Director may also be responsible to develop trainings and quality improvement interventions to support optimal PAC outcomes including readmission prevention program for 90 days post discharge.

In this role, you will:

• Conduct medical necessity reviews adhering to regulatory and compliance turnaround times and issues adverse determinations as needed.
• Provide guidance to licensed and non-licensed associates on clinical issues and case reviews related to authorization requests and clinical guidelines criteria.
• Provide education to UM team to support Post Acute Care needs, discharge planning, length of stay management and readmission reduction.
• Complete peer-to-peer discussions as indicated at the time of PAC facility admissions when medical necessity criteria are not met, to facilitate proactive discharge planning or when facility stay is no longer medically indicated.
• Participates in CareCentrix Care Coordination, Utilization Management, Quality Improvement and clinical education activities, as requested.
• Utilize clinical integrity and professionalism in all determinations and interactions with internal and external partners.
• Collaborate with Account Management and Health Plan clinical leadership as requested.
• Interface with key positions within CareCentrix including reporting to the Senior Medical Director and interacting with the Chief Medical Officer and executive team members.
• Collaborate with Market Engagement Directors and facility provider Joint Operations Committee activities as requested/needed.
• Successfully completes and passes the annual Inter-rater reliability testing and random case audits.
• Achieves Service Level Agreement (SLA) metrics and performance guarantees as required by health plan clients.
• Scheduled weekend work is required

You should get in touch if you have:

• MD or DO with an active and unencumbered medical license. Must have active ABIM or ABMS specialty board certification(s). The candidate may be asked to obtain additional licenses as needed.
• 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
• Expertise in Medicaid health plan or UM is preferred
• Excellent written and verbal communication skills.
• Interest quality improvement and project a positive attitude toward all assigned work.
• Adheres to and participates in Company's mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.

What we Offer:

• Full range of benefits including Health, Dental and Vision with HSA Employer Contributions and Dependent Care FSA Employer Match.
• Generous PTO, 401K Savings Plan, Paid Parental Leave, free on-demand Virtual Fitness Training and more.
• Advancement opportunities, professional skills training, and tuition Reimbursement
• Great culture with a sense of community.

We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.