Hybrid Medical Director

at CareSource

• Job title: Medical Director
• Job type: Full Time
• Experience level: Lead
• Salary: $195,200 - $341,600 per year
• Degree requirement: Postgraduate Degree
• Location requirements: Hybrid, United States

About the role

• Medical Director role supporting staff with training and clinical review at CareSource. Overseeing quality improvement and compliance functions alongside developing care standards.

Responsibilities

• The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members.
• 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
• Collaborate with market/product leaders to help define market strategy
• 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

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
• 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
• MCG Certification is required or must be obtained within six (6) months of hire

Benefits

• bonuses tied to company and individual performance
• substantial and comprehensive total rewards package