Medical Director(Must Live In Massachusetts)

CareSource•Massachusetts WFH, MA

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. This role involves performing prior authorization medical reviews, participating in peer-to-peer discussions, and providing provider education. The Medical Director will conduct clinical reviews for designated CareSource members, provide physician review for clinical appeals cases, and participate in the evaluation of cases suspected of fraud, abuse, and quality of care concerns. Additionally, the role contributes to the development of policies and procedures, quality improvement initiatives, case management activities, and member safety. The Medical Director will also provide cross-coverage for other Medical Directors and/or markets as needed, assist in reviewing utilization data, and participate in the development and revision of clinical care standards, practice guidelines, and the Quality Improvement Plan. Collaboration with market/product leaders to define market strategy and participation in community collaboratives and support of regulatory and accreditation functions are also key aspects of this position.

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
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

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
Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer)

Responsibilities

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