Implements policies and standards, evaluate new treatments, and conduct medical research to ensure the quality of the medical care provided to patients. Implements utilization and financial initiatives. Develops and manages efforts to improve and maintain cost and utilization trends. Requires an MD or DO.
SUMMARY: The Medical Principal performs medical necessity review and case management activities. The physician provides clinical insight to the organization through peer review, benefit review, peer to peer conversations, consultation, and service to internal and external customers.
RESPONSIBILITIES:
- 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.
Qualifications:
Required – Current unrestricted medical license in 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 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.
- Experience in medical management, utilization review and case management in a managed care setting is a plus.
- 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 asks 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.
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.
About The Cigna Group
Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives.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 reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
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