Medical Director

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

📋 Description

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

• Engage in peer-to-peer discussions.

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

• Execute clinical reviews for assigned CareSource members.

• Perform physician reviews for clinical appeal cases.

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

• Formulate policies and procedures.

• Participate in quality improvement, case management, and member safety initiatives.

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

• Supervise and enhance case management activities.

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

• Create, implement, and revise clinical care standards and practice guidelines.

• Develop, implement, and revise the Quality Improvement Plan alongside corporate quality initiatives.

• Collaborate with market and product leaders to shape market strategies.

• Engage in community collaborations.

• Support regulatory, accreditation, and compliance functions for CMS, State, NCQA, and URAC programs.

• Execute other job-related instructions 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 required.

• A minimum of five years of clinical practice experience is necessary.

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

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

• Specialty-board recertification must be maintained as needed.

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

• Basic skills in Microsoft Word are required.

• Excellent written and verbal communication skills are essential.

• Ability to work independently as well as collaboratively within a team environment.

• Capability to build relationships with providers and members.

• High ethical standards and meticulous attention to detail are required.

• Strong critical listening and systematic thinking abilities.

• Capacity to maintain confidentiality and act in the company’s best interest.

• Diplomacy and sensitivity towards cultural diversity.

• Skills in decision-making, problem-solving, and conflict resolution.

• Commitment to dedicating time, effort, and resources to the communities served.

• Availability to work evenings and weekends may be required.

• Travel may be necessary to fulfill position responsibilities.

🏝️ Benefits

• Potential bonus linked to company and individual performance.

• Comprehensive and substantial total rewards package.

• Support for employee well-being.

• Equal Opportunity Employer environment emphasizing belonging and support.