Medical Director, Occupational Health & Workers’ Managed Care

US Telecommuter

Full time

R74438

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve.

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Medical Director, Occupational Health & Workers’ Compensation Managed Care

PRIMARY PURPOSE : To evaluate medical reports escalated due to deficient information utilizing evidence based criteria; to provide leadership within the dedicated team of clinician and claim professionals in support of the dedicated program through training and implementation of medical best practices; and to provide client facing support when needed for additional services supporting Human Resources with ADAAA and FMLA support that require medical expertise;

to adhere to service delivery time frames, customer satisfaction, and overall support of workflow.

Physician Leadership | Disability & Return-to-Work | Managed Care | Clinical Strategy. Experience with insurance carriers, TPA's, or managed care organizations extremely helpful!

ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work.

• Emerging medical trends and clinical strategy: Stay current on emerging medical trends, treatment standards, clinical literature, and evidence-based guidelines; support client conversations and operational decisions tied to these trends.

• Customer-Facing: Strategic face to face partnership in client stewardship discussions, claim round tables, and complex medical escalations.

• Travel Expectations: 25%-30%.

• Claims and occupational health expertise: Support workers’ compensation, disability, FMLA, fitness-for-duty, return-to-work, liability, and safety-sensitive workforce issues.

• Managed Care: Experience in the managed care industry. Can support operational needs as required specific to Utilization Review and Physician Advisor Support, care management strategy, vendor alignment, and quality improvement..

• Licensure support: Obtain and maintain Medical Director licensure in a few select states, as needed, to support regulatory, Managed Care, utilization review, and operational requirements.

• Evidence-based medical guidance: Apply applicable clinical guidelines and medical literature to support defensible recommendations, claim discussions, treatment-plan clarification, and return-to-work/disability-related decision-making.

• Provider, appeal, and quality support: Engage treating providers when needed and support appeals, independent medical review considerations, peer review alignment, and clinical quality review.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Responsible for evaluating the following:

• Conducting reviews on cases where the nurse is seeking treatment plan clarification, claim denial, disability certification or duration management for return to work guidance.

• Generating phone calls to treating physicians to enter into a motivational conversation to create an environment for positive discussion outlining the facts and evidence to make appropriate claim determinations.

• Documenting recommendations within templates in Juris and SharePoint using the appropriate format referencing evidence-based criteria within the required time frame.

• The oversight of the appeal and review process including making a recommendation of specialty for the Independent Medical Review process.

• Developing and delivering training materials and presentations to…