US Telecommuter · Remote
Full-time
Mid level
4 days ago
Apply link not verified recently — we re-check every 2 hours
Salary undisclosed
By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance SVP Medical Director PRIMARY PURPOSE : To evaluate medical reports escalated due to deficient information utilizing evidence based criteria; to provide leadership within the dedicated team of clinician and claim professionals in support of the dedicated program through training and implementation of medical best practices; and to provide client facing support when needed for additional services supporting Human Resources with ADAAA and FMLA support that require medical expertise; to adhere to service delivery time frames, customer satisfaction, and overall support of workflow. ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work. Client-facing clinical support: Participate in client stewardship discussions, claim roundtables, and complex medical escalations. Travel Expectations: 25%-30%. Emerging medical trends and clinical strategy: Stay current on emerging medical trends, treatment standards, clinical literature, and evidence-based guidelines; support client conversations and operational decisions tied to these trends. Claims and occupational health expertise: Support workers’ compensation, disability, FMLA, fitness-for-duty, return-to-work, liability, and safety-sensitive workforce issues. Managed Care / UR support: Can support operational needs as required specific to Utilization Review and Physician Advisor Support, care management strategy, vendor alignment, and quality improvement.. Licensure support: Obtain and maintain Medical Director licensure in a few select states, as needed, to support regulatory, Managed Care, utilization review, and operational requirements. Evidence-based medical guidance: Apply applicable clinical guidelines and medical literature to support defensible recommendations, claim discussions, treatment-plan clarification, and return-to-work/disability-related decision-making. Provider, appeal, and quality support: Engage treating providers when needed and support appeals, independent medical review considerations, peer review alignment, and clinical quality review. ESSENTIAL FUNCTIONS and RESPONSIBILITIES Responsible for evaluating the following: Conducting reviews on cases where the nurse is seeking treatment plan clarification, claim denial, disability certification or duration management for return to work guidance. Generating phone calls to treating physicians to enter into a motivational conversation to create an environment for positive discussion outlining the facts and evidence to make appropriate claim determinations. Documenting recommendations within templates in Juris and SharePoint using the appropriate format referencing evidence-based criteria within the required time frame. The oversight of the appeal and review process including making a recommendation of specialty for the Independent Medical Review process. Developing and delivering training materials and presentations to meet training needs. Interfacing and providing guidance and leadership to the Client dedicated leadership team as well as team leads where appropriate. Following established policy and procedures to assure compliance to best practices, service standards, state regulations, and client service requirements and assure efficient, cost effective, quality program delivery for medical and disability management. Coordinating and evaluating the service delivery between the company, partners, and vendors. Member of a client Disabi
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