Medical Director

  • 16945 Northchase Dr, Houston, TX 77060, USA
  • Employees can work remotely
  • Full-time

Company Description

HealthHelp - A WNS Company (www.HealthHelp.com), is the leader in the field of healthcare utilization & care management. We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach. Our methodology helps payors achieve a higher return on investment, gives providers education programs that better inform physicians, and ensures quality and safety for the patients needing treatment.

HealthHelp’s innovative approach and strong IT capability in specialty benefits management means that staff will move healthcare forward when provided with evidence-based solutions and second opinions. HealthHelp's staff is comprised of healthcare professionals who make a difference every day. HealthHelp has a desire to fill their company with talented and innovative people who want a career path filled with success and personal growth.

Our specialty benefits management services are broad and include, Cardiology, Oncology, Radiology, Radiation Therapy, Sleep Care, and Musculoskeletal Care. HealthHelp has two locations in Houston, one a corporate office and the second a state-of-the art contact center. HealthHelp is also proud to have another such contact center in Albany, New York.

WNS Global Services Inc. (NYSE: WNS) is a global Business Process Management (BPM) leader. WNS offers business value to 400+global clients by combining operational excellence with deep domain expertise in key industry verticals, including Banking and Financial Services, Consulting and Professional Services, Healthcare, Insurance, Manufacturing, Retail and Consumer Packaged Goods, Shipping and Logistics, Telecommunications, Travel and Utilities. Globally, the group’s over 44,000+ Professionals serve across 60 delivery centers in 16 countries worldwide.

Job Description

•    Determines the medical necessity of requests using clinical criteria.
•    Performs physician-level case review of utilization requests.
•    Conducts peer-to-peer consultation with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, surgical procedures, imaging and appropriate sites of service.
•    Provides education regarding applicable clinical criteria and discusses clinically appropriate alternative surgical and nonsurgical treatments.
•    Performs first level provider appeals of coverage decisions.
•    Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate diagnoses, treatments, and management. 
•    Participates in physician team meetings.
•    Participates in groups that develop, revise and enhance clinical appropriateness guidelines.

Qualifications

Qualifications
•    Requires M.D. or D.O. Board certification in either Family Practice, Internal Medicine or Emergency Medicine.
•    Current unrestricted medical license(s) as a Doctor of Medicine in appropriate state(s) and willing to obtain state specific licensing, as required.
•    5 years of clinical practice experience past fellowship training preferred.
•    5 years of experience with utilization management, especially with CMS guidelines preferred.
•    Experience crafting CMS and state Medicaid appropriate denial language as part of the utilization review process.
•    Intermediate computer skills strongly preferred.

Additional Information

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