Sr. VP Medical Director

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.

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Sr. VP 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 a are driven to deliver great work.

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.

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.

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. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $169,000-$237,000.00. 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.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.

Sedgwick is the world’s leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company’s expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see sedgwick.com