EXL (NASDAQ: EXLS) is a leading operations management and analytics company that designs and enables agile, customer-centric operating models to help clients improve their revenue growth and profitability. Our delivery model provides market-leading business outcomes using EXL’s proprietary Business EXLerator Framework™, cutting-edge analytics, digital transformation and domain expertise. At EXL, we look deeper to help companies improve global operations, enhance data-driven insights, increase customer satisfaction, and manage risk and compliance. EXL serves the insurance, healthcare, banking and financial services, utilities, travel, transportation and logistics industries. Headquartered in New York, New York, EXL has more than 26,000 professionals in locations throughout the United States, Europe, Asia (primarily India and Philippines), South America, Australia and South Africa. For more information, visit www.exlservice.com.
The Senior Medical Director plays a vital role on driving measurable and meaningful improvement in the use of evidence-based medicine, patient safety, practice variation and affordability in serving our clients Medicare, Medicaid, and commercial members. The Senior Medical Director is responsible for clinical direction and support to the clinical staff on a daily basis (Utilization Management and all Care Management programs). This position is responsible for making medical necessity determinations on cases where the clinical reviewer is unable to approve the services requested. This position is further responsible for peer to peer conversations during the review process, as well as provider education regarding the medical management process. The Senior Medical Director has a critical role in the monitoring of quality of care and services provided, as well as providing input into the quality of the internal processes. This position is responsible for the supervision of the Medical Directors and Associate Medical Directors, for medical services. The Senior Medical Director participates in client and provider network meetings as needed.
• Reviews medical/surgical cases for medical necessity
• Engages daily and ongoing with frontline clinical review nurses, reviewing cases electronically or in verbal case discussion, with the goals of achieving evidence-based and data-driven delivery of clinically appropriate and cost-effective care
• Develop, directs, supervise the activities of Medical Directors
• Provides clinical education and leadership to nursing and other clinical staff
• Leverages evidence-based medicine, nationally recognized clinical guidelines to coach clinical staff and support providers in the provision of appropriate, high quality and cost-effective care
• Regularly engages in peer-to-peer dialogue with practicing providers to convey UM determinations and discuss care of individual patients to develop collaborative intervention plans based upon EBM.
• Provides appeal determinations as needed
• Participates in client meetings as appropriate to discuss the clinical programs
• Assists and leads as appropriate clinical design of key programs
• Provide strategic leadership of medical management programs to increase efficiency and effectiveness of care delivery
• Interpret medical policy criteria for associates to facilitate the application of policy in pre-certification, concurrent review and case management
• Participates on key product, quality and other committees as required
• Assist with the monitoring and trending of utilization data, case management data and disease management data
• Supports decision-making responsibilities regarding medical matters
• Optimize utilization of medical resources to maximize benefits for members while supporting initiatives
• Supports and leads a team environment that is results oriented and recognizes individual contribution
• Concisely and articulately documents case review findings, actions and outcomes in electronic systems, and meets medical director inter-rater reliability and quality guidelines.
• Initiates and maintains verbal and/or electronic communication with all appropriate stakeholders (patients, providers and clients) related to the status and action plans for the case.
• Adheres to clinical documentation standards to ensure efficient case review, communication with team members and to facilitate timely and efficient determinations and claims adjudication.
• Participates in the management of complex medical cases and collation of clinical information to assess and expedite assessment of care needs. This includes obtaining and reviewing verbal and written medical reports/records.
• Pro-actively engages providers to review, discuss, and develop solutions for complex member situations.
• Participates in routine team meetings, training and ongoing educational activities as well as policy and procedure development.
• Conducts high cost claims reviews for individual cases and engages in high cost claims reviews rounds.
• Serves as a clinical educator and facilitates achievement of appropriate patient care goals through coaching of nurses and conducting peer-to-peer communication with practicing physicians.
• Performs all other duties as assigned
A medical degree from an accredited medical school and board certification (MD or DO) in either Internal Medicine or Family Practice
Current, unrestricted license to practice as a health professional in a state or territory of the United States required, with the ability to obtain license in any other state or territory of the United States as needed.