Medical Director

CareSource; Northern (KY); Híbrido; USD 195.000 - 342.000; Jornada completa

Descripción de la vacante

CareSource is seeking a Medical Director to lead clinical review activities, provide education to providers, and support quality and regulatory initiatives across markets. The role emphasizes oversight of case management, data-driven improvements, and collaboration with market leadership.

The position requires DO or MD, board certification, residency in primary care, and a minimum of five years of clinical practice, with managed care experience preferred. Occasional travel may be involved.

Formación

• DO or MD required to practice medicine.
• Residency in primary care preferred.
• Five years of clinical practice experience required.
• Current, unrestricted medical license in state of practice.
• Board Certification in primary care preferred.
• MCG Certification required within six months of hire.
• Managed care medical review experience preferred.

Responsabilidades

• Provide clinical review services as directed.
• Participate in peer-to-peer discussions.
• Educate providers, training, data sharing, and performance evaluations.
• Review designated CareSource member cases.
• Provide physician review for clinical appeals cases.
• Investigate fraud, abuse, and quality of care concerns.
• Develop and revise clinical care standards and guidelines.
• Support regulatory and accreditation functions (CMS, state, NCQA, URAC).
• Perform other job-related duties as requested.

Conocimientos

Communication skills

Independent work

Relationship building

Attention to detail

Ethical standards

Critical thinking

Confidentiality

Diplomacy & cultural sensitivity

Decision making & problem solving

Conflict resolution

Mission-driven

Educación

DO

MD

Business/Admin/Healthcare mgmt degree

Primary care residency

Five years clinical practice

Managed care medical review experience

Herramientas

Microsoft Word

Descripción del empleo

Job Summary

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

Essential Functions

• 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.

Education and Experience

• Doctor of Osteopathic Medicine (DO) required or
• Medical Doctor (MD) required
• Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is preferred
• Successful completion of a residency training program, preferably in primary care is required
• Five (5) years of clinical practice experience required
• Managed care medical review/medical director experience 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 skillsConflict 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 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

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time
• May be required to work evenings/weekends
• Up to 15% (Occasional) travel to attend meetings, trainings, and conferences may be required

Salary

$195,200.00 - $341,600.00 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.

Organization Level Competencies

• Fostering a Collaborative Workplace Culture
• 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 environment of belonging that welcomes and supports individuals of all backgrounds.