Medical Director

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

📋 Description

• Assist staff through training, clinical consultation, and the review of clinical cases for members.

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

• Engage in peer-to-peer discussions.

• Offer provider education, training, data sharing, performance assessments, and orientation to the plan.

• Execute clinical reviews for specified CareSource members.

• Perform physician evaluations for clinical appeal cases.

• Take part in investigations regarding suspected fraud, abuse, and quality-of-care issues.

• Formulate policies, procedures, clinical care standards, practice guidelines, and quality enhancement plans.

• Participate in activities related to quality improvement, case management, member safety, regulatory compliance, and accreditation.

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

• Analyze utilization data to detect pattern variances and offer feedback and education.

• Collaborate with market/product leaders to define market strategies.

• Engage in community collaboratives.

• Carry out other job-related instructions as requested.

⛳️ Requirements

• A completed 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 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 proficiency in Microsoft Word is needed.

• Exceptional written and verbal communication skills are essential.

• Ability to work both independently and collaboratively within a team environment.

• Capacity to build strong relationships with providers and members.

• High ethical standards and meticulous attention to detail.

• Skills in critical listening and systematic thinking.

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

• Diplomatic and sensitive to cultural diversity.

• Proficient decision-making, problem-solving, and conflict-resolution skills.

• A current, unrestricted license to practice medicine in the state of practice, as required by regulations.

• Board certification, preferably in a primary care specialty, is a requirement.

• Maintain specialty-board recertification as necessary.

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

• Availability to work evenings and weekends may be necessary.

• Travel may be required.

🏝️ Benefits

• A bonus linked to company and individual performance may be available.

• A comprehensive total rewards package.

• Employee well-being support.

• An equal opportunity and belonging-focused work environment.