Enterprise Medical Director, Post-Service Review & Medical Claims Review (MCR)

CareSource•Dayton, OH

2d•$195,200 - $341,600•Hybrid

About The Position

The Enterprise Medical Director is responsible for the development, implementation and revision of corporate level clinical care standards and practice guidelines, ensuring compliance with nationally accepted quality standards. For Medical Claims Review (MCR) assignments, the Enterprise Medical Director serves as the clinical leader for physician-led post-service audits and payment integrity activities involving high-dollar claims, Hospital Acquired Conditions (HACs), quality-of-care concerns, and other claims requiring medical judgment. The Enterprise Medical Director is responsible for evaluating medical records, clinical documentation, claims data, and audit findings to assess medical necessity, clinical appropriateness, quality-of-care considerations, and potential payment recovery opportunities. The role partners closely with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics to support the development, implementation, governance, and continuous improvement of the MCR program. In addition, the Enterprise Medical Director provides leadership for the MCR operating model, Medical Director review team, clinical audit methodologies, physician review standards, and expansion of the capability beyond the initial HAC and high dollar claims proof of concept. The role supports provider engagement, audit findings, disputes, appeals, and related clinical review activities while helping scale MCR as a strategic enterprise payment integrity and clinical audit capability.

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
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
MCG Certification is required or must be obtained within six (6) months of hire
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
Ability to analyze healthcare data from a variety of sources to evaluate physician practice patterns
Leadership experience and skills

Nice To Haves

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

Responsibilities

Development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives
Development of policies and procedures
Medical Director Operational leadership, Medical Economics Analytics
Identify utilization management trends and take appropriate action
Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
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
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
Collaborate with market/product leaders to help define market strategy
Provides oversight and direction of assigned managers and associates
Perform any other job duties as requested
Serves as the clinical leader for physician-led post-service audits and payment integrity activities involving high-dollar claims, Hospital Acquired Conditions (HACs), quality-of-care concerns, and other claims requiring medical judgment.
Evaluating medical records, clinical documentation, claims data, and audit findings to assess medical necessity, clinical appropriateness, quality-of-care considerations, and potential payment recovery opportunities.
Partners closely with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics to support the development, implementation, governance, and continuous improvement of the MCR program.
Provides leadership for the MCR operating model, Medical Director review team, clinical audit methodologies, physician review standards, and expansion of the capability beyond the initial HAC and high dollar claims proof of concept.
Supports provider engagement, audit findings, disputes, appeals, and related clinical review activities while helping scale MCR as a strategic enterprise payment integrity and clinical audit capability.