Medical Director, Post-Service Review, Medical Claims Review

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

📋 Description

• Deliver clinical review services and conduct clinical case assessments for members.

• Engage in peer-to-peer discussions.

• Provide education, training, data sharing, performance evaluations, and onboarding for providers within the plan.

• Perform clinical reviews for assigned CareSource members.

• Conduct physician reviews for clinical appeals cases.

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

• Formulate policies, procedures, clinical care standards, practice guidelines, Quality Improvement Plans, and corporate quality initiatives.

• Take part in activities related to quality improvement, case management, member safety, regulatory compliance, accreditation, and adherence to standards.

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

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

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

• Engage in community collaboratives.

• For MCR assignments, act as the physician reviewer for post-service clinical audits and payment integrity activities involving high-value claims, HACs, quality-of-care issues, and other claims necessitating medical judgment.

• Review medical records, clinical documentation, claims data, and audit results to assess medical necessity, clinical appropriateness, quality-of-care factors, and recovery opportunities for payments.

• Collaborate with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics teams.

• Support provider discussions, audit results, disputes, appeals, and ongoing improvement initiatives related to the enterprise MCR capability.

• Carry out additional job-related tasks as assigned.

⛳️ Requirements

• Doctor of Osteopathic Medicine (DO) or Medical Doctor (MD) is required.

• 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 is necessary to comply with regulatory requirements.

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

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

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

• Proficient in basic Microsoft Word skills.

• Exceptional written and verbal communication skills are essential.

• Capacity to work autonomously as well as collaboratively within a team environment.

• Ability to foster strong relationships with Providers and Members.

• High ethical standards are essential.

• Strong attention to detail is required.

• Possess critical listening and systematic thinking abilities.

• Capability to maintain confidentiality and act in the best interest of the company.

• Ability to approach situations with diplomacy and sensitivity to cultural diversity.

• Strong decision-making and problem-solving skills.

• Proficient in conflict resolution techniques.

• Deep commitment to the mission and the communities served is important.

• 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.

🏝️ Benefits

• Bonus opportunities linked to company and individual performance may be available.

• A comprehensive total rewards package is offered.

• Up to 15% travel may be required to attend meetings, training sessions, and conferences.