Overview - Medical Review Physician (Remote/Onsite)

Salary Range: ($175k-$195k) depending on experience and qualifications.

Would you like to make the most of your clinical skills by providing high-quality professional guidance and case reviews on complicated cases? Are you a team player who enjoys collaborating with colleagues and stakeholders to optimize the administration of health care benefits? SGS/MCA is looking for a detail-oriented Medical Review Physician who can assess environmental exposures and complicated health conditions to ensure optimal access to indicated services.

The Medical Review Physician provides support to the Medical Services Teams, working under the supervision of the Medical Director. This role is responsible for rendering all required medical reviews, recommendations, and clinical determinations according to client-specified timelines. All client inquires will be responded to within established timeframes.

The Medical Review Physician may also provide consultation services related to clinical medicine, medical policy, health benefits, and disability systems; develop and/or deliver training materials; participate in research and analysis related to risks and outcomes; write protocols or procedures; participate in quality improvement activities; and provide support to other core business lines. 

Responsibilities

Medical Determinations

• The clinical assessment regarding program and benefit eligibility will be conducted in accordance with the specific requirements outlined by the client based on medical evidence.
• As directed by client-specific requirements, determine if environmental exposure thresholds, latency periods or maximum time intervals have been met for claimed conditions.
• Perform physician reviews to support utilization activities to determine if program coverage criteria are met for requested healthcare services, including but not limited to utilization management, pharmacy, and eligibility for treatment for program-covered conditions.
• Complete all reviews and render determinations in the requisite timeframes.
• Adhere to SGS-MCA and client-specific protocols.
• Where applicable, ensure rendered clinical determinations are provided in writing to the claimant and/or other stakeholders.
• Work with the clinical management team in the development or revision of clinical protocols, policies, procedures, and templates.
• Notify the supervisor if any quality concerns arise.
• Provide clinical subject matter expertise to clinical teams and supporting business units, as needed and/or in the absence of the medical director.

 Case management

• Perform physician reviews on complex cases under case management to assist in the development of the case management plan.
• Provide clinical support to the case management and utilization review team for training, policy and procedures, and quality assurance activities.
• Adhere to SGS-MCA protocols related to case management recommendations and strategies.

Quality

• Develop and deliver on personal quality improvement goals (e.g. SMART goals).
• Lead or participate in cross-department, company-wide, or client-specific quality improvement initiatives.
• Participate in the SGS-MCA peer audit process.
• Support client-directed audit processes.

Training

• Collaborate with the Medical Director, Pharmacy Services Manager, Chief Medical Officer; SVP, Case Management; Senior VP, Client Services, and Chief Operating Officer to identify and meet the training needs of the case management team, account management, and technical solutions staff.
• Participate in the development and delivery of training to staff and customers.

Meetings

• Attend internal and external client meetings as needed.
• Attend required in-person and remote SGS-MCA staff meetings.
• Participate in clinical team meetings.
• May perform other duties, as needed, to meet the needs of the business

Qualifications

• Medical degree (MD or DO)
• Unrestricted and current license to practice medicine in one US State
• Minimum of 10 years of relevant clinical experience
• Minimum of 5 years of experience with occupational medicine or other health care programs that enables them to make independent clinical decisions and recommendations for specialty or limited benefit health care programs and their member populations
• Minimum of 2 years clinical experience with a Federal Health Care Program (includes DoD)
• Excellent oral and written communication skills.
• Strong investigation and organizational skills.
• Demonstrated ability to influence without authority through the employment of strong interpersonal skills.
• Ability to work in a team environment
• Proficiency in Microsoft Office
• United States Citizenship
• Must be able to obtain and maintain confidential-level security clearance(s) as required

For a career path that is both challenging and rewarding, join Sedgwick Government Solution’s talented team. Taking care of people is at the heart of everything we do. Our clients depend on our talented colleagues to take care of their most valuable assets—their employees, and their customers. At Sedgwick Government Solutions, caring counts®. Join our team of creative and caring people of all backgrounds and help us make a difference in the lives of others.

Sedgwick Government Solutions provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of a specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is ($175,000 - $195,000). A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.

To be considered for this position, please submit a resume, and complete the application.

The information provided above has been designed to indicate the general nature and level of work of the position. It is not a comprehensive inventory of all duties, responsibilities, and qualifications required.

Important Information

Successful candidates will be required to undergo a financial and criminal background check and obtain and maintain confidential-level security clearance upon hire. We participate in the United States Federal Government E-Verify program to confirm the employment authorization of the employee upon hire. 

Search Firm Representatives  

Please be advised that Sedgwick Government Solutions (Government Solutions) is not seeking assistance or accepting unsolicited resumes from search firms for this employment opportunity. Regardless of past practice, a valid written agreement and task order must be in place before any resumes are submitted to Government Solutions. All resumes submitted by search firms to any employee at Government Solutions without a valid written agreement and task order in place will be deemed the sole property of Government Solutions and no fee will be paid in the event that person is hired by Government Solutions.

Government Solutions strives to make our career site accessible to all users. If you need a disability-related accommodation to complete the application process, please contact Government Solutions regarding accommodations. 

Sedgwick Government Solutions is an Equal Opportunity and Affirmative Action Employer

All qualified applicants will receive consideration for employment without regard to age, citizenship status, color, disability, marital status, national origin, race, religion, sex, sexual orientation, gender identity, veteran status, or any other classification protected by federal state or local laws as appropriate, or upon the protected status of the person’s relatives, friends or associates.

Sedgwick Government Solutions abides by the requirements of 41 CFR 60-741.5(a). This regulation prohibits discrimination against qualified individuals on the basis of disability and requires affirmative action by covered prime contractors and subcontractors to employ and advance in employment qualified individuals with disabilities.

Sedgwick Government Solutions abides by the requirements of 41 CFR 60-300.5(a). This regulation prohibits discrimination against qualified protected veterans and requires affirmative action by covered prime contractors and subcontractors to employ and advance in employment qualified protected veterans.

About Sedgwick

Sedgwick Government Solutions is a fully owned subsidiary of Sedgwick. Sedgwick is a leading global provider of technology-enabled risk, benefits, and integrated business solutions. Taking care of people is at the heart of everything we do. Millions of people and organizations count on Sedgwick each year to take care of their needs when they face a major life event or something unexpected happens. The company provides a broad range of resources tailored to clients' specific needs in casualty, property, marine, benefits, and other lines. At Sedgwick, caring counts®; through the dedication and expertise of more than 27,000 colleagues across 65 countries, the company takes care of people and organizations by mitigating and reducing risks and losses, promoting health and productivity, protecting brand reputations, and containing costs that can impact the bottom line. www.sedgwick.com Privacy | Sedgwick Terms and Conditions | Sedgwick