Medical Director

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