Offer summary

Qualifications:

Completion of an accredited Medical Degree (MD or DO) is required., Successful completion of a residency training program, preferably in primary care, is required., Minimum of five years of clinical practice experience is required., Managed care medical review/medical director experience is preferred. .

Key responsabilities:

Support staff by providing training, clinical consultation, and clinical case review for members.

Participate in peer-to-peer discussions and provide provider education and training.

Conduct clinical reviews for designated CareSource members and support regulatory functions.

Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns.

Job description

Job Summary:

Medical Directors support CareSource staff by providing training, clinical consultation, and clinical case review for members.

Essential Functions:

Support staff by providing training, clinical consultation, and clinical case review for members
Participate in peer-to-peer discussions
Provide provider education, training, data sharing, performance evaluations and orientation to the plan
Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
Participate in development of policies and procedures
Provide cross-coverage for other Medical Directors and/or markets, as needed
Provide prior authorization medical reviews, consultation and clinical review services
Conduct clinical reviews for designated CareSource members
Clinical Appeals
Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
Managed care medical review/medical director experience is required.
Managed care appeals determinations experience with multiple lines of business (e.g. Medicaid, Medicare, Marketplace) is required.
Perform any other job duties 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 review/medical director experience is preferred
Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is 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 making/problem 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
Board Certification, preferably in primary care specialty is required; re-certification, as required by specialty board, must be maintained

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time
May be required to work evenings/weekends
Ability to travel as required by the needs of the business

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 well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies