Job Summary:The Clinical Appeals Medical Director will perform medical necessity review of appeals, within the organization, ensuring timely, accurate, quality and compliant review of clinical appeals. Administers the decision-making process related to appeals, supports clinical operations, and facilitates communication among stakeholders.
Essential Functions:- Review and make determinations on complex clinical appeals in accordance with medical guidelines, internal policy, state and regulatory requirements
- Provide clinical expertise and guidance in the evaluation of appeals related to medical necessity and appropriateness of care.
- Collaborated with cross functioning teams including legal, compliance, utilization management and provider relations to ensure consistent, timely and fairness and appeals adjudication
- Support the development and implementation of clinical guidelines and protocols to standardize the appeals process and improve outcomes.
- Serve as a liaison between the organization, internal and external stakeholders.
- Participate in quality assurance initiatives to enhance the overall effectiveness of the clinical appeals process.
- Stay current with industry trends, regulations, and best practices related to clinical appeals and managed care.
- Maintain required state licensure and board certification status.
- Perform any other job related duties as requested.
Education and Experience:- Doctoral Medical degree (MD or DO) from an accredited institution. required
- Bachelor's or Master's degree in Business Administration, Healthcare Administration or Medical Management preferred
- Successful completion of a residency training program required
- Five (5) years Clinical practice experience required
- Five (5) years Managed care medical review/medical director experience preferred
Competencies, Knowledge and Skills:- Excellent verbal and written communication skills
- Clinical decision making
- Healthcare policy knowledge
- Appeals processing
- Stakeholder communication
- Medical expertise
- Outcomes improvement
- Policy adherence
- Familiarity with medical necessity criteria and clinical guidelines.
Licensure and Certification:- Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements required
- Board certification in a relevant clinical specialty required
- Re-certification as required by specialty board must be maintained
- MCG Certification is required or must be obtained withing six 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 additional hours outside normal business hours including evenings, weekends and holidays
- Ability to travel as required by the needs of the department.
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
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 environment of belonging that welcomes and supports individuals of all backgrounds.
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