REMOTE - Medical Director - R12971

Job Summary

The Clinical Appeals Medical Director will perform medical necessity review of appeals, ensuring timely, accurate, quality and compliant review of clinical appeals. They will administer the decision-making process related to appeals, support clinical operations, and facilitate communication among stakeholders.

Essential Functions

• Review and make determinations on complex clinical appeals in accordance with medical guidelines, internal policy, state and regulatory requirements
• Provide clinical expertise and guidance in the evaluation of appeals related to medical necessity and appropriateness of care
• Collaborate with cross-functioning teams including legal, compliance, utilization management and provider relations to ensure consistent, timely and fair appeals adjudication
• Serve as a liaison between the organization, internal and external stakeholders
• Participate in quality assurance initiatives to enhance the overall effectiveness of the clinical appeals process
• Stay current with industry trends, regulations, and best practices related to clinical appeals and managed care

Education And Experience

• Doctoral Medical degree (MD or DO) from an accredited institution. Required
• Bachelor's or Master's degree in Business Administration, Healthcare Administration or Medical Management preferred
• Successful completion of a residency training program required
• Five (5) years Clinical practice experience required
• Five (5) years Managed care medical review/medical director experience preferred

Competencies, Knowledge and Skills

• Excellent verbal and written communication skills
• Clinical decision making
• Healthcare policy knowledge
• Appeals processing
• Stakeholder communication
• Clinical expertise
• Outcomes improvement
• Policy adherence
• Familiarity with medical necessity criteria and clinical guidelines

Licenses and Certifications

• Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements required
• Board certification in a relevant clinical specialty required
• Re-certification as required by specialty board must be maintained
• MCG Certification is required or must be obtained within six 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 additional hours outside normal business hours including evenings, weekends and holidays
• Ability to travel as required by the needs of the department

Compensation

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.

Competencies

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