Executive Medical Director DME/IRF

Medical Director DME/IRF Summary: The Medical Director DME & IRF oversees intraday activities of EviCore’s Durable Medical Equipment and Inpatient Rehabilitation Facility management programs and services. Responsibilities include: Serve as program internal lead for DME clinical guideline and policy management Work with Guideline Manager to create eviCore DME guidelines Maintain and update DME denial rationales Represent EviCore in audits or case discussions specifically arranged around Medicare or Medicaid policies regarding DME and IRF issues/decisions Work with pathways team and provide clinical support for development of DME clinical pathways Create quarterly DME IRR quiz and hold quarterly debrief with physicians after quiz is completed Assist in case audits to assess the accuracy of Associate Medical Directors’ & Medical Directors’ decision making and adherence to the EviCore criteria and processes Hold regular 1:1 meetings (alternating with program chief) with DME/IRF associate medical directors/medical directors Provide weekend coverage to complete urgent DME & IRF appeals that cannot be completed by the on call PAC/DME associate medical director/medical director Testify at ALJ Hearings when your cases are being appealed or adjudicating Associate Medical Director is unavailable Provide audit support for DME & IRF cases reviewed during CMS and client audits Assist with interviewing, onboarding, and training new DME/IRF Associate Medical directors Serve as a Subject Matter Expert and first point of contact for Associate Medical Directors who are seeking assistance with problematic case reviews, or escalated cases that deserve immediate review and attention Respond to urgent, expedited, or escalated DME and IRF cases and P2Ps Assist in reviewing case determinations from clients responding to a provider or member complaint Assist in responding to notifications and requests to amend incorrect reviews when the physician reviewer who initially reviewed the case is n