CareSource

Medical Director

• Assume responsibility for the overall safety of patients with a BH diagnosis, with a special focus on safe prescribing
• Serve as the clinical lead in developing and implementing evidenced based clinical policies and practices
• Participate in regulatory/accreditation reviews
• Assume key role in quality improvement initiatives, case management activities and member safety activities (i.e. incident management)
• BH coverage determination for utilization management to ensure members receive appropriate and medically necessary care in the most cost-effective setting
• Oversight and quality improvement activities associated with case management activities
• Provide guidance to BH orientation and network development/ recruitment in conjunction with provider relations, value-based contracting, support of episodes of care and full integration of BH services
• Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate
• Represent CareSource as the primary clinical liaison to members, providers and State agencies
• Support of regulatory and accreditation functions (e.g. CMS, State, NCQA and URAC) and compliance for all programs
• 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
• Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
• Provide cross-coverage for other Medical Directors and/or markets, as needed
• Support staff by providing training, clinical consultation, and clinical case review for members including Medical Advisement meetings
• Perform any other job duties as requested

Behavioral Health Medical Director

• 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.

Systems Engineer

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Behavioral Health Medical Director

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