Encore Medical Principal

About the position

The Medical Principal at The Cigna Group is responsible for performing medical necessity reviews and case management activities, providing clinical insights through peer reviews and consultations, and ensuring quality outcomes for customers. This role involves balancing patient advocacy with business needs while participating in various quality processes and mentoring other medical professionals.

Responsibilities
? Performs benefit-driven medical necessity reviews for coverage, case management, and claims resolution.
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? Works to achieve quality outcomes for customers/members with a focus on service and cost.
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? Improves clinical outcomes through daily interactions with health care professionals using active listening, education, and excellent communication and negotiation skills.
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? Balances customer/member needs with business needs while serving as a customer/member advocate at all times.
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? Participates in all levels of the Appeal process as appropriate.
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? Participates in coverage guideline development and maintenance of medical management projects and committees.
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? Participates in quality processes such as audits, inter-rater reliability clinical reviews, and quality projects.
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? Serves as a mentor or coach to other Medical Directors and colleagues in quality and performance improvement processes.
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? Improves health care professional relations through direct communication and fostering positive collegial relationships.
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? Addresses customer service issues with mentoring and support from leadership staff.
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? Investigates and responds to client and/or regulatory questions to assist in resolving issues or clarifying questions.
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? Achieves internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring timely turn-around of coverage reviews and quality outcomes based on those review decisions.
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? Provides clinical insight and management support to other functional areas and matrix partners as needed or directed.

Requirements
? Current unrestricted medical license in US state or territory.
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? Current board certification in an ABMS or AOA recognized specialty.
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? Minimum of 5 years of clinical practice experience and/or direct patient care beyond residency.
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? Computer competency in word processing, spreadsheet, email, and personal information management programs.
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? Experience in medical management, utilization review, and case management in a managed care setting is a plus.
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? Knowledge of managed care products and strategies.
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? Ability to work within a changing business environment and balance patient advocacy with business needs.
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? Experience with managing multiple tasks in a fast-paced matrix environment.
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? Demonstrated ability to educate colleagues and staff members.
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? Successful experience and comfort with change management.
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? Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem-solving skills.
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? Successful ability to assess complex issues, determine and implement solutions, and resolve problems.
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? Success in creating and maintaining cooperative, successful relations with diverse internal and external stakeholders.
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? Demonstrated sensitivity to culturally diverse situations, participants, and customers/members.

Nice-to-haves
? Experience in a managed care setting.
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? Familiarity with clinical guidelines and best practice principles.

Benefits
? Flexible work options including occasional or permanent work from home.
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? Support for professional development and continuing education.

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