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 Disability Pension Board + Review of identified appeal cases for quality assurance purposes + Voting member to determine if eligibility requirements have been met + Quarterly meeting attendance telephonically or virtually + Provides MRO expertise in special cases where a case is escalated. + Provides assistance where occupational health expertise is needed. + Collaborates with other parts of the company as needed.

ADDITIONAL

FUNCTIONS and

RESPONSIBILITIES

+ Performs other duties as assigned. + Supports the organization's quality program(s). + Travels as required.

SUPERVISORY RESPONSIBILITIES

+ Provides support, guidance, leadership and motivation to promote maximum performance. + Administers company personnel policies in all areas and follows company staffing standards and training recommendations. + Interviews, hires and establishes colleague performance development plans; conducts colleague performance discussions. Education & Licensing Medical Doctor (M.D.) degree required.

TAKING CARE OF YOU BY

+ Offering a blended work environment. + Supporting meaningful work that promotes critical thinking and problem solving. + Providing on-going learning and professional growth opportunities. + Promoting a strong team environment and a culture of support. + Recognizing your successes and celebrating your achievements. + Thrives when everyone is working towards the same vision/goals. + We offer a diverse and comprehensive benefits package including: + Three medical, and two dental & vision plans to choose from. + Tuition reimbursement + 401K plan that matches 50% on every $ you put in up to the first 6% you save. + 4 weeks PTO your first full year. ? When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental:

?Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical:

?Computer keyboarding.

Auditory/Visual:

Hearing, vision and talking ? Experience Ten (10) of related experience required to include one (1) to three (3) years utilization review experience and three (3) years clinical quality control. Skills & Knowledge + Knowledge of evidence-based guidelines + Knowledge of ADAA and FMLA + Knowledge of utilization review procedures + Knowledge of clinical quality systems and measurements + Knowledge of resources available regarding regulations and parameters of third party reimbursement, benefit determinations and payments + Knowledge of statutory requirements of state's jurisdiction/ ERISA regulations + Knowledge about general claim practices. + Knowledge of pharmacy processes and pharmacy benefit management a plus. + Understanding of pain management a plus. + Excellent oral and written communication skills, including presentation skills + PC literate, including Microsoft Office products + Analytical and interpretive skills + Strong organizational skills + Excellent interpersonal skills + Proven management/leadership skills + Ability to create and complete comprehensive, accurate and constructive written reports + Ability to work in a team environment + Ability to meet or exceed Performance Competencies _As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. 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