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Medical Director – Appeals, Managed Care, Family Medicine

Medical DirectorMedical DirectorOtherRemoteLeadTeam 1,001-5,000Since 30+ yearsH1B SponsorCompany SiteLinkedIn

Location

United States

Posted

173 days ago

Salary

$195.2K - $341.6K / year

Seniority

Lead

Postgraduate Degree5 yrs expEnglish

Job Description

Medical Director – Appeals, Managed Care, Family Medicine

CareSource

• The Medical Director is responsible for supporting 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

Job Requirements

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

Benefits

  • bonuses tied to company and individual performance
  • substantial and comprehensive total rewards package

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