Job Summary:The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members.
Essential Functions:- 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
- Participates 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 (eg. CMS, State, NCQA and URAC) and compliance for all programs
- Perform any other job related instructions, as requested
Education and Experience:- 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
Competencies, Knowledge and 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/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 state of practice as necessary to meet regulatory requirements is required
- Board Certification, preferably in 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
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 - 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.#LI-SW2
