Medical Director

CareSource • Dayton, OH

6d • $195,200 - $341,600 • Hybrid

About The Position

The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members. This role involves providing clinical review services, participating in peer-to-peer discussions, and educating providers on plan operations and performance. The Medical Director will conduct clinical reviews for designated CareSource members, provide physician review for clinical appeals, and participate in investigations of potential fraud, abuse, and quality of care concerns. Additionally, the role contributes to the development of policies, procedures, quality improvement initiatives, case management, and member safety activities. The Medical Director will also provide cross-coverage for other Medical Directors, oversee quality improvement related to case management, and assist in reviewing utilization data to identify variances and provide feedback. Collaboration with market/product leaders to define market strategy and participation in community initiatives are also key aspects of this position. The role supports regulatory and accreditation functions, ensuring compliance with CMS, State, NCQA, and URAC standards.

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
• 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
• 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

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.

Benefits

• Bonus tied to company and individual performance
• Substantial and comprehensive total rewards package

What This Job Offers

• Job Type: Full-time
• Career Level: Senior