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 Medical Director plays a vital role in both the development and implementation of clinical program designs, policies/procedures and strategies. The Medical Director is responsible for clinical direction and support to the UM/CM and Disease Management staff on a daily basis. This position is responsible for making medical necessity determinations on cases where the RN 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 Medical Director has a critical role in the monitoring of quality of care and services provided within the network, as well as providing input into the quality of the internal review process. The Medical Director participates in client and provider network meetings as needed.
• Reviews cases for medical necessity
• Provides clinical education and leadership to nursing and other clinical staff
• Participates in peer to peer conversations as needed to convey UM determinations or to explain review processes
• Participates in client meetings as appropriate to discuss the UM/CM programs
• Assists and leads as appropriate clinical design of key programs
• 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
• Other duties as requested and/or assigned by the Chief Medical Officer
• Assists with business development, sales and marketing efforts by participating in prospective client meetings/presentations.
Ability to perform across multiple electronic platforms and/or systems is required.
Experience with multiple platforms is helpful. required.
Ability to interact appropriately with other physicians, nursing staff, management staff, business leaders, and clients.
M.D. or D.O. degree, Board Certified in Internal Medicine or Family Medicine required.
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.
Work Experience Requirements:
Minimum five (5) years active medical practice experience required, preferably in both inpatient and outpatient settings. The maintaining of an active clinical practice via: moonlighting, PRN, PT, or volunteer basis, etc. is required. Available CME days can be used for this purpose. Managed care experience to include utilization management, case management and/or disease management preferred and/or a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review preferred. Experience responding to appeals and/or grievances helpful.