Medical Director – Appeals, Managed Care, Family Medicine
CareSource
full-time
Posted on:
Location Type: Remote
Location: United States
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Salary
💰 $195,200 - $341,600 per year
Job Level
About the role
- 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
- 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
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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical consultationclinical case reviewprior authorization medical reviewsprovider educationclinical reviewsutilization data reviewquality improvement initiativescase managementfraud investigationpolicy development
Soft Skills
trainingcommunicationcollaborationleadershipperformance evaluationdata sharingorientationcross-coveragefeedback provisioncommunity participation
Certifications
Medical Degree (MD or DO)Board CertificationMCG Certification