Medical Director (REMOTE Appeals Medical Director - Pacific Standard Time, Manag

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