Job Summary:
The Enterprise Medical Director is responsible for the development, implementation, and revision of corporate level clinical care standards and practice guidelines, ensuring compliance with nationally accepted quality standards.
Essential Functions:
- Development, implementation, and revision of the Quality Improvement Plan and corporate level quality initiatives.
- Development of policies and procedures.
- Medical Director Operational leadership, Medical Economics Analytics.
- Identify utilization management trends and take appropriate action.
- Support regulatory and accreditation functions (e.g., CMS, State, NCQA, and URAC) and compliance for all programs.
- Support staff by providing training, clinical consultation, and clinical case review for members.
- Participate in peer-to-peer discussions.
- Provide provider education, training, data sharing, performance evaluations, and orientation to the plan.
- Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns.
- Provide cross-coverage for other Medical Directors and/or markets, as needed.
- Provide prior authorization medical reviews, consultation, and clinical review services.
- Conduct clinical reviews for designated CareSource members.
- Clinical Appeals.
- Collaborate with market/product leaders to help define market strategy.
- Provide oversight and direction of assigned managers and associates.
- Perform any other job duties as requested.
Education and Experience:
- Completion of an accredited Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic (DO) medicine is required.
- Successful completion of a residency training program, preferably in primary care, is required.
- Minimum of five (5) years of clinical practice experience is required.
- Managed care medical review/medical director experience is preferred.
- Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration, or Medical Management is preferred.
Competencies, Knowledge, and Skills:
- Basic Microsoft Word skills.
- Excellent communication skills, both written and oral.
- Ability to work well independently and within a team environment.
- Ability to create strong relationships with Providers and Members.
- High ethical standards.
- Attention to detail.
- Critical listening and systematic thinking skills.
- Ability to maintain confidentiality and act in the company’s best interest.
- Ability to act with diplomacy and sensitivity to cultural diversity.
- Decision making/problem solving skills.
- Conflict resolution skills.
- Strong sense of mission and commitment of time, effort, and resources to the betterment of the communities served.
- Ability to analyze healthcare data from a variety of sources to evaluate physician practice patterns.
- Leadership experience and skills.
Licensure and Certification:
- Current, unrestricted license to practice medicine in the state of practice as necessary to meet regulatory requirements is required.
- Board Certification, preferably in primary care specialty, is required; re-certification, as required by specialty board, must be maintained.
- MCG Certification is required or must be obtained within six (6) months of hire.
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time.
- May be required to work evenings/weekends.
- Ability to travel as required by the needs of the business.
Compensation Range:
$187,600.00 - $328,300.00. CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type:
Salary
Competencies:
- Create an Inclusive Environment
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer, including disability and veteran status. We are committed to a diverse and inclusive work environment.
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