Medical Director (REMOTE Appeals Medical Director Pacific Standard Time, Managed Care ExperienceAppeals Experience Preferred)

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 peertopeer 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 crosscoverage for other Medical Directors andor 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 marketproduct 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 reviewmedical director experience and experience with appeals are 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 makingproblem 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
      • Willingness to acquire additional licenses as needed per regulatory contractual requirements, with organizational support
      • Board Certification, preferably in primary care specialty is required
      • Recertification, 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 eveningsweekends
        • May be required to travel to fulfill duties of position

        • Compensation Range:

          $191,400.00 $334,900.00

          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 wellbeing and offer a substantial and comprehensive total rewards package.

          Compensation Type (hourlysalary):

          Salary

          Organization Level Competencies

          • Create an Inclusive Environment

          • Cultivate Partnerships

          • Develop Self and Others

          • Drive Execution

          • Influence Others

          • Pursue Personal Excellence

          • Understand the Business

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            This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.

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