Position Summary:

The Clinical Enterprise department provides clinical business support to the entire company and provides clinical support for Capital Rx’s clinical utilization management (UM) programs, consultative support to the Pharmacy and Therapeutics (P&T) process, formulary development, drug information services and client activities as assigned. This position will report to the Lead Medical Director. This position transacts UM activities (prior authorization and appeals) and responds to prescriber inquiries related to UM transactions and more generally related to Capital Rx’s coverage policies. Medical Directors represent the clinical decision making and professional thought process of the prescriber as a stakeholder across the enterprise.

Position Responsibilities:

• Medical Director will complete assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients; governmental (Medicare/Medicaid) programs and individual client requested coverage determinations or appeals when appropriate
• Makes clinical determinations in accordance with medical necessity and criteria
• Performs scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to requesting prescribers
• Follow all internal procedures, job aids, and HIPPA guidelines to protect patient privacy and data security
• Support the Department’s responsibilities to provide peer-to-peer phone call support to physicians/prescribers who call the company with specific and general questions about our clinical programs, communications and utilization review decisions
• Communicates effectively and confidently with members to promote positive health outcomes
• Actively participates in the development of utilization management (PA) criteria and clinical policy revisions/reviews
• Ability to work in a fast-paced environment with shifting priorities
• Weekend on-call responsibilities (shared rotating call)
• Attention to detail and commitment to delivering high-quality work

Minimum Qualifications:

• Must be a graduate of an accredited Medical School and Residency Program
• Active Texas medical license, required
• No history of disciplinary actions on Medical License
• Minimum 5 years history of clinical practice with direct patient care
• Specialty-Internal Medicine
• Board certified by appropriate Medical Board (DO, MD)
• Be able to satisfy rotating weekend call schedule with another Medical Director
• Possess an unrestricted active license to practice medicine in a State, Territory, Commonwealth of the United States, or the District of Columbia
• Required annual Continuing Medical Education (CME) up to date and must remain current in medical and management areas during employment
• Demonstrated experience in clinical outcomes, working knowledge of medical statistics, regulatory agencies, and analytic programs
• Ability to work with virtual teams of pharmacists
• Time management skills to meet organizational goals
• Knowledge of PBM environment, quality improvement and UM practices in a managed care environment
• Knowledge of and appreciation for requirements of regulatory and accreditation agencies
• Able to manage multiple priorities and deadlines
• Excellent verbal, written, interpersonal and presentation skills
• Strong knowledge of clinical medicine, health care delivery and the ability to acquire new scientific and medical knowledge
• Proficiency with Microsoft Office applications. (e.g., MS Word, Excel, and PowerPoint minimum)

Preferred Qualifications:

• Subspecialty board certification in addition to internal medicine (i.e. Rheumatology, Gastroenterology)
• Willing to obtain additional medical license
• Licensed in multiple states. Unrestricted without disciplinary actions (AZ, NC, MN, MI, TN or others)