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

CareSource•Dayton, OH

2d•$195,200 - $341,600•Onsite

About The Position

The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members. For Medical Claims Review (MCR) assignments, the Medical Director serves as the physician reviewer for post-service clinical audits and payment integrity activities involving high-dollar claims, Hospital Acquired Conditions (HACs), quality-of-care concerns, and other claims requiring medical judgment. The Medical Director is responsible for evaluating medical records, clinical documentation, claims data, and audit findings to determine medical necessity, clinical appropriateness, quality-of-care considerations, and potential payment recovery opportunities. This role partners closely with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics teams to support physician-led post-service review activities. The role also supports provider discussions, audit findings, disputes, appeals, and continuous improvement initiatives associated with the enterprise Medical Claims Review (MCR) capability.

Requirements

Doctor of Osteopathic Medicine (DO) required or Medical Doctor (MD) required
Successful completion of a residency training program, preferably in primary care is required
Five (5) years of clinical practice experience required
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
Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements required
Board Certification, preferably in primary care specialty required
Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer) required
MCG Certification is required or must be obtained within six (6) months of hire required

Nice To Haves

Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is preferred
Managed care medical review/medical director experience preferred

Responsibilities

Provide clinical review services as directed
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 duties as requested.
Serves as the physician reviewer for post-service clinical audits and payment integrity activities involving high-dollar claims, Hospital Acquired Conditions (HACs), quality-of-care concerns, and other claims requiring medical judgment.
Evaluates medical records, clinical documentation, claims data, and audit findings to determine 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 teams to support physician-led post-service review activities.
Supports provider discussions, audit findings, disputes, appeals, and continuous improvement initiatives associated with the enterprise Medical Claims Review (MCR) capability.