Medical Director

Caresource Dayton , OH 45401

Posted 3 weeks ago

Role and Responsibility:

  • 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

  • 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

Requirements

Education / 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

Required Competencies / Knowledge /

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 / 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)

Working Conditions:

  • General office environment; required to use general office equipment

  • May be required to work evenings/weekends

  • May be required to travel to fulfill duties of position

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Medical Director

Caresource