Medical Director

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

📋 Description

• Conduct medical reviews for prior authorization, offering consultation and clinical review services.

• Engage in peer-to-peer discussions.

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

• Perform clinical reviews for assigned CareSource members as required.

• Review clinical appeals cases in collaboration with physicians.

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

• Contribute to the development of policies and procedures.

• Join initiatives focused on quality improvement, case management, and member safety.

• Provide cross-coverage support for other Medical Directors and/or markets as necessary.

• Oversee and improve quality related to case management activities.

• Analyze utilization data to detect inconsistencies and offer feedback and education to MCP staff and providers.

• Engage in the development, implementation, and revision of clinical care standards and practice guidelines.

• Involve in the development, implementation, and revision of the Quality Improvement Plan along with corporate-level quality initiatives.

• Collaborate with market/product leaders to help shape market strategies.

• Participate in community collaboratives.

• Support compliance with regulatory and accreditation requirements, including CMS, State, NCQA, and URAC.

• Execute other job-related tasks as assigned.

• Availability to work evenings and weekends may be required.

• Willingness to travel as needed to fulfill job responsibilities.

⛳️ Requirements

• An accredited Medical Degree program completion as either an MD or DO is essential.

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

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

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

• Board Certification, preferably in a primary care specialty, is required.

• Re-certification must be maintained as stipulated by the specialty board.

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

• Basic proficiency in Microsoft Word is required.

• Exceptional written and verbal communication skills are essential.

• Ability to work autonomously as well as collaboratively in a team setting.

• Capability to foster strong relationships with Providers and Members.

• Adherence to high ethical standards is crucial.

• Strong attention to detail is necessary.

• Critical listening and systematic thinking skills are required.

• Ability to maintain confidentiality and act in the company's best interests.

• Diplomatic and culturally sensitive approach is essential.

• Proficient decision-making and problem-solving skills are necessary.

• Conflict resolution abilities are required.

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

• Previous experience in managed care medical review or as a medical director is preferred.

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

🏝️ Benefits

• Potential bonus linked to both company and individual performance.

• Comprehensive total rewards package offered.

• Support for employee total well-being.