Enterprise Medical Director

Job Summary :

The Enterprise Medical Director is responsible for the development, implementation and revision of corporate level clinical care standards and practice guidelines, ensuring compliance with nationally accepted quality standards.

Essential Functions :

• Development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives
• Development of policies and procedures
• Medical Director Operational leadership, Medical Economics Analytics
• Identify utilization management trends and take appropriate action
• Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
• Support staff by providing training, clinical consultation, and clinical case review for members
• Participate in peer-to-peer discussions
• Provide provider education, training, data sharing, performance evaluations and orientation to the plan
• Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
• Provide cross-coverage for other Medical Directors and / or markets, as needed
• Provide prior authorization medical reviews, consultation and clinical review services
• Conduct clinical reviews for designated CareSource members
• Clinical Appeals
• Collaborate with market / product leaders to help define market strategy
• Provides oversight and direction of assigned managers and associates
• Perform any other job duties as requested

Education and Experience :

Competencies, Knowledge and Skills :

Licensure and Certification :

Working Conditions :

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 :

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 environment of belonging that welcomes and supports individuals of all backgrounds.

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