Job Summary:
The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members.
Essential Functions:
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Provide prior authorization medical reviews, consultation and clinical review services
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Participate in peer-to-peer discussions
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Provide provider education, training, data sharing, performance evaluations and orientation to the plan
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Conduct clinical reviews for designated CareSource members as requested
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Provide physician review for clinical appeals cases
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Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
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Participate in development of policies and procedures
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Participates in quality improvement initiatives, case management activities and member safety activities (i.e. incident management
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Provide cross-coverage for other Medical Directors and/or markets, as needed
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Oversight and quality improvement activities associated with case management activities
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Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate
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Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards
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Participate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives
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Collaborate with market/product leaders to help define market strategy
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Community collaborative participation
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Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
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Perform any other job related instructions, as requested
Education and Experience:
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Completion of an accredited Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic (DO) medicine is required
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Successful completion of a residency training program, preferably in primary care is required
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Minimum of five (5) years of clinical practice experience is required
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Managed care medical review/medical director experience is preferred
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Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is preferred
Competencies, Knowledge and Skills:
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Basic Microsoft Word skills
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Excellent communication skills, both written and oral
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Ability to work well independently and within a team environment
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Ability to create strong relationships with Providers and Members
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High ethical standards
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Attention to detail
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Critical listening and systematic thinking skills
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Ability to maintain confidentiality and act in the company’s best interest
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Ability to act with diplomacy and sensitivity to cultural diversity
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Decision making/problem solving skills
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Conflict resolution skills
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Strong sense of mission and commitment of time, effort and resources to the betterment of the communities served
Licensure and Certification:
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Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements is required
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Board Certification, preferably in primary care specialty is required
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Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer)
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MCG Certification is required or must be obtained within six (6) months of hire
Working Conditions:
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General office environment; may be required to sit or stand for extended periods of time
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May be required to work evenings/weekends
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May be required to travel to fulfill duties of position
Compensation Range:
$195,200.00 - $341,600.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
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