[Remote] Medical Director (REMOTE Appeals Medical Director - Pacific Standard Time, Managed Care Experience, Family Medicine, Internal Medicine-Pediatrics and Appeals Experience Preferred") - R11319

Note: The job is a remote job and is open to candidates in USA. CareSource is a managed care organization seeking a Medical Director to support staff through training, clinical consultation, and case reviews. The role involves providing prior authorization medical reviews, conducting clinical reviews, and participating in quality improvement initiatives.

Responsibilities

• 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

Skills

• 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
• 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
• 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
• 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

Benefits

• 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.

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