Medical Director
Humana
Medical Director, Appeals
CareSource
full-time
Posted on:
Origin: • 🇺🇸 United States • Ohio
Visit company websiteSalary
💰 $191,400 - $334,900 per year
Job Level
Lead
About the role
- Provide APPEALS 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.
- Weekend call in rotation with other medical directors.
- 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 (MD) or Doctor of Osteopathic (DO)
- Successful completion of residency training program, preferably in primary care
- Minimum of five (5) years of clinical practice experience
- Managed care medical review/medical director experience and experience with appeals preferred
- Board Certification, preferably in primary care specialty is required
- Willingness to acquire additional licenses as needed per regulatory/ contractual requirements
- MCG Certification is required or must be obtained within six (6) months of hire
