Enterprise Medical Director

This is a fully remote position, open to applicants in United States.

📋 Description

• Development, execution, and revision of the Quality Improvement Plan along with corporate-level quality initiatives.

• Formulation of policies and procedures.

• Operational leadership as Medical Director, along with Medical Economics Analytics.

• Analyze utilization management trends and implement necessary actions.

• Support for regulatory and accreditation functions (including CMS, State, NCQA, and URAC) as well as compliance for all programs.

• Assist staff by providing training, clinical consultation, and clinical case reviews for members.

• Engage in peer-to-peer discussions.

• Deliver provider education, training, data sharing, performance evaluations, and orientation to the plan.

• Take part in the evaluation and investigation of cases suspected of fraud, abuse, and quality of care issues.

• Offer cross-coverage for other Medical Directors and/or markets as required.

• Conduct prior authorization medical reviews, consultations, and clinical review services.

• Perform clinical reviews for designated CareSource members.

• Collaborate with market/product leaders to help establish market strategy.

• Provide oversight and guidance to assigned managers and associates.

• Execute any other job duties as assigned.

⛳️ Requirements

• An accredited Medical Degree program completion as a medical doctor (MD) or Doctor of Osteopathic (DO) medicine is mandatory.

• Successful completion of a residency training program, preferably in primary care, is required.

• At least five (5) years of clinical practice experience is necessary.

• Experience in managed care medical review/medical director roles is preferred.

• A Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration, or Medical Management is preferred.

• A current, unrestricted license to practice medicine in the state of practice, as required to meet regulatory standards, is obligatory.

• Board Certification, preferably in a primary care specialty, is required; re-certification as mandated by the specialty board must be upheld.

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

🏝️ Benefits

• A substantial and comprehensive total rewards package.