[Hiring] Medical Director, Post-Service Review & Medical Claims Review @CareSource

Role Description

The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members.

• Provide clinical review services as directed
• Participate in peer-to-peer discussions
• Provide provider education, training, data sharing, performance evaluations and orientation to the plan
• Conduct clinical reviews for designated CareSource members as requested
• Provide physician review for clinical appeals cases
• Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
• Participate in development of policies and procedures
• Participate in quality improvement initiatives, case management activities and member safety activities (i.e. incident management)
• Provide cross-coverage for other Medical Directors and/or markets, as needed
• Oversight and quality improvement activities associated with case management activities
• Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate
• Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards
• Participate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives
• Collaborate with market/product leaders to help define market strategy
• Community collaborative participation
• Support of regulatory and accreditation functions (e.g. CMS, State, NCQA and URAC) and compliance for all programs
• Perform any other job related duties as requested.

Qualifications

• Doctor of Osteopathic Medicine (DO) required or Medical Doctor (MD) required
• Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is preferred
• Successful completion of a residency training program, preferably in primary care is required
• Five (5) years of clinical practice experience required
• Managed care medical review/medical director experience preferred

Requirements

• Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements required
• Board Certification, preferably in primary care specialty required
• Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer) required
• MCG Certification is required or must be obtained within six (6) months of hire required

Benefits

• Compensation Range: $195,200.00 - $341,600.00
• In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
• Substantial and comprehensive total rewards package.

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time
• May be required to work evenings/weekends
• Up to 15% (Occasional) travel to attend meetings, trainings, and conferences may be required

Organization Level Competencies

• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.