Executive Medical Director DME​/IRF

Medical Director DME/IRF Summary

• Serve as program internal lead for DME clinical guideline and policy management
• Work with Guideline Manager to create eviCore DME guidelines
• Maintain and update DME denial rationales
• Represent Evi Core in audits or case discussions specifically arranged around Medicare or Medicaid policies regarding DME and IRF issues/decisions
• Work with pathways team and provide clinical support for development of DME clinical pathways
• Create quarterly DME IRR quiz and hold quarterly debrief with physicians after quiz is completed
• Assist in case audits to assess the accuracy of Associate Medical Directors’ & Medical Directors’ decision making and adherence to the Evi Core criteria and processes
• Hold regular 1:1 meetings (alternating with program chief) with DME/IRF associate medical directors/medical directors
• Provide weekend coverage to complete urgent DME & IRF appeals that cannot be completed by the on call PAC/DME associate medical director/medical director
• Testify at ALJ Hearings when your cases are being appealed or adjudicating Associate Medical Director is unavailable
• Provide audit support for DME & IRF cases reviewed during CMS and client audits
• Assist with interviewing, onboarding, and training new DME/IRF Associate Medical directors
• Serve as a Subject Matter Expert and first point of contact for Associate Medical Directors who are seeking assistance with problematic case reviews, or escalated cases that deserve immediate review and attention
• Respond to urgent, expedited, or escalated DME and IRF cases and P2
  
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• Assist in reviewing case determinations from clients responding to a provider or member complaint
• Assist in responding to notifications and requests to amend incorrect reviews when the physician reviewer who initially reviewed the case is not available
• Manage the day-to-day clinical activities of the eviCore DME/IRF Program
• Collaborate with leadership from Clinical Operations, Non-clinical Operations, and Program Operations to support and promote optimal program functioning and identify opportunities for improvement
• Supervise and manage activities of the DME/IRF program’s Medical Directors and Associate Medical Directors to ensure effective and objective application of clinical guidelines, accurate determination of medical necessity, and efficient processing of clinical case review requests in accordance with legal and contractual obligations
• Support the development and maintenance Evi Core policies and procedures and criteria related to clinical certification
• Coordinate the clinical development and education of the DME/IRF program’s Medical Directors and Associate Medical Directors through collection/circulation of educational materials, organization of quarterly educational sessions, and other activities as appropriate
• Evaluate the performance of the DME/IRF program’s Medical Directors and Associate Medical Directors.
• Serve as a coach, mentor, and/or clinical supervisor for specific Medical Directors and/or Associate Medical Directors
• Support the review of Evi Core clinical guidelines
• Support sales and client management teams as clinical representative for designated program when requested by Program Chief
• Provide timely expert medical review of medical necessity requests for clinical services and renders a clinical opinion about the medical service under review, including post-decision reviews, when necessary to support timely completion of clinical cases within the designated program
• Maintain necessary credentials and immediately informs Evi Core of any adverse actions relating to medical licenses and/or board certifications
• Support and communicates eviCore policies and procedures to the provider community.
• Participate in all required educational and quality improvement activities and maintain passing scores in all assessments
• Other duties as assigned

• M.D. or D.O. degree from accredited institution.
• Minimum of five (5) years of clinical practice experience after completion of all graduate medical education training, including residency and fellowship (when applicable) Active board certification in Physical…