Medical Director

About the Role

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

Responsibilities

• Provide prior authorization medical reviews, consultation, and clinical review services
• 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 (e.g., incident management)
• Provide cross-coverage for other Medical Directors and/or markets, as needed
• Oversee and improve quality 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 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
• Engage in community collaborative participation
• Support regulatory and accreditation functions (e.g., CMS, State, NCQA, and URAC) and compliance for all programs
• Perform any other job-related instructions, as requested

Requirements

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

Skills

• Basic Microsoft Word skills
• Excellent communication skills, both written and oral
• Ability to work well independently and within a team environment
• Ability to create strong relationships with providers and members
• High ethical standards
• Attention to detail
• Critical listening and systematic thinking skills
• Ability to maintain confidentiality and act in the company’s best interest
• Ability to act with diplomacy and sensitivity to cultural diversity
• Decision-making and problem-solving skills
• Conflict resolution skills
• Strong sense of mission and commitment of time, effort, and resources to the betterment of the communities served

Licensure and Certification

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

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time
• May be required to work evenings/weekends
• May be required to travel to fulfill duties of position

Pay

$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.

Benefits

We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.