Medical Director- Oncology/Hematology

Job description

Summary description of position:  A Medical Director performs medical review and case management activities.  The physician provides clinical insight to the organization through peer review, benefit review, consultation, and service to internal and external customers.  He/she will serve as a clinical educator and consultant to utilization management, case management, network, contracting, pharmacy, and service operations (claims).  This is an entry to mid-level position for a physician interested in a career in health care administration.

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.
• Participates in coverage guideline development, development, and maintenance of medical management projects, 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 medical license in a US state or territory
• Current board certification in an ABMS or AOA recognized specialty (grandfathered by the board or maintained by the MOC program)
• Exhibits ethical and professional behavior.
• Minimum of 5 years of clinical practice experience in oncology and hematology and/or direct patient care beyond residency
• Computer Competency: Word processing, Spreadsheet, Email, and Personal Information Management programs are used extensively and competency in all must be possessed or rapidly acquired.  Must be able to research clinical issues on internet resources

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.
• Fluency in Spanish (CHS) or other languages

Company Description

We’re a global health service company dedicated to helping people improve their health, well-being and sense of security. We offer an integrated suite of health services, such as medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products that serve over 95 million customers around the world.  When you work with us, you’ll enjoy a different kind of career - you’ll make a difference, learn a ton, and change the way people think about health insurance. To see our culture in action, search #TeamCigna on Twitter or Instagram.