Medical Director

CareSourceDayton, OH, United States

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Job Summary :

The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members.

Essential Functions :

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

Education and Experience :

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

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

Competencies, Knowledge and Skills :

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

Licensure and Certification :

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 (exceptions may be granted by Chief Medical Officer)

MCG Certification is required or must be obtained within six (6) months of hire

Working Conditions :

General office environment; may be required to sit or stand for extended periods of time

May be required to work evenings / weekends

May be required to travel to fulfill duties of position

Compensation Range :

191,400.00 - $334,900.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type : Salary

Competencies :

Create an Inclusive Environment - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.

LI-SW2

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Medical Director • Dayton, OH, United States