Enterprise Medical Director, Post-Service Review, Medical Claims Review

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

📋 Description

• Create, implement, and update corporate-level clinical care standards, practice guidelines, the Quality Improvement Plan, and quality initiatives.

• Formulate policies and procedures.

• Offer operational leadership for the Medical Director and Medical Economics Analytics.

• Recognize utilization management trends and take necessary actions.

• Assist with regulatory, accreditation, and compliance functions for CMS, state, NCQA, and URAC requirements.

• Deliver staff training, clinical consultation, and clinical case review for members.

• Engage in peer-to-peer discussions.

• Provide education, training, data sharing, performance evaluations, and orientation for providers.

• Assess and investigate suspected fraud, abuse, and quality-of-care concerns.

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

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

• Carry out clinical reviews for designated CareSource members.

• Manage clinical appeals.

• Collaborate with market and product leaders to define market strategy.

• Oversee and guide assigned managers and associates.

• Act as a clinical leader for physician-led post-service audits and payment integrity activities related to high-dollar claims, HACs, quality-of-care concerns, and claims needing medical judgment.

• Review medical records, clinical documentation, claims data, and audit findings for medical necessity, clinical appropriateness, quality of care, and payment recovery opportunities.

• Collaborate with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics on MCR program development, implementation, governance, and continuous improvement.

• Lead the MCR operating model, Medical Director review team, clinical audit methodologies, physician review standards, and capability expansion.

• Facilitate provider engagement, audit findings, disputes, appeals, and related clinical review activities.

• Perform additional duties as requested.

⛳️ Requirements

• Completion of an accredited Medical Degree program as an MD or DO is mandatory.

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

• A minimum of five (5) years of clinical practice experience is required.

• 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.

• Basic skills in Microsoft Word are necessary.

• Excellent written and oral communication abilities are required.

• Capability to work independently and collaboratively within a team environment is essential.

• Ability to establish strong relationships with Providers and Members is important.

• High ethical standards are crucial.

• Attention to detail is required.

• Critical listening and systematic thinking skills are necessary.

• Ability to maintain confidentiality and act in the company’s best interest is essential.

• Must be able to act with diplomacy and sensitivity to cultural diversity.

• Strong decision-making and problem-solving skills are required.

• Conflict resolution skills are important.

• A strong sense of mission and commitment to the communities served is necessary.

• Ability to analyze healthcare data from various sources to evaluate physician practice patterns is required.

• Leadership experience and skills are essential.

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

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

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

🏝️ Benefits

• Bonus opportunities based on company and individual performance may be available.

• A comprehensive total rewards package is offered.

• Support for employee total well-being is provided.