Provides administrative oversight to the medical staff
Analyzes medical review utilization data
Researches new medical procedures or technology
Acts as a resource to providers and internal staff on issues concerning medical policies
Writes and revises medical policies
Supports operations in the form of case review on both medical and regulatory matters
Develops claim adjudication criteria for situations requiring medical judgment
Provides input on issues and operational policies, processes, and procedures
Educates staff and medical community on various aspects of medical policy and program administration
Develops and updates medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies
Develops external relationships with the medical community and serves as liaison between these entities and the contractors
Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization
Conducts research into new or controversial medical procedures and technology

Doctorate in a job related field
5 years post graduate experience in direct patient care
Microsoft Office proficiency
Excellent verbal and written communication skills
Excellent customer service, organizational, and presentation skills
Good judgment skills
Proficiency in spelling, punctuation, and grammar
Ability to persuade, negotiate, or influence others
Ability to work as a team member as well as a leader
Knowledge of medical and utilization review techniques
Active state medical license and current board certification in a recognized specialty.

Medicare Medical Director

Key skills