Medical Director

CareSource•Delaware WFH, DE

2d•$195,200 - $341,600•Hybrid

About The Position

The Medical Director, Neonatology is responsible for providing subject matter expertise and medical leadership in the development of utilization management, care management and quality of care programs for infant and neonatology services. This role involves working directly with Vice Presidents and Medical Directors to achieve desired objectives, supporting staff through training and consultation, and providing prior authorization medical reviews. The position also entails provider education, clinical appeals review, and participation in investigations of potential fraud, abuse, or quality of care concerns. Additionally, the Medical Director will engage in quality improvement initiatives, analyze utilization data, and contribute to the development and revision of clinical care standards, practice guidelines, and quality improvement plans. Collaboration with market/product leaders to define market strategy and serve as a liaison to community organizations and health systems regarding neonatal care is also a key aspect. The role supports regulatory and accreditation functions and involves active participation in Utilization Management rounds, education of UM staff on NICU utilization, and improving transitions of care for NICU members. The Medical Director will also help create formal clinical policy for NICU and post-NICU transitions/care management.

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 in pediatrics and neonatology fellowship required or equivalent experience
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 (Pediatrics) is required as well as board certification in Neonatology
Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer)
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 desirable

Responsibilities

Work directly with Vice Presidents of Utilization Management, Care Management and Medical Directors to achieve desired utilization, care management and quality of care objectives for this newborn and infant members and their mothers
Support staff by providing training, clinical consultation, and clinical case review for members
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
Provide physician review for clinical appeals cases
Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
Participates in quality improvement initiatives, case management activities and member safety activities (i.e. incident management
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 managed care plan 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
Work with market leaders to be a liaison to community based organization and health systems regarding neonatal care both prevention and care coordination and management
Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
Actively participate in Utilization Management (UM) rounds and education of UM staff on NICU utilization management, levels of care and quality of care
Participate in the development /ongoing improvement in the transitions of care for NICU members that graduate from NICU
Actively participate in creating of formal clinical policy for NICU and post NICU transitions/care management
Perform any other job duties as requested