Medical Director (REMOTE Appeals Medical Director - Eastern Standard Time (EST) Main Work Hours, Managed Care Experience / Appeals Experience Preferred)

Job Summary :The Medical Director is responsible for appeals medical necessity determinations, for supporting staff by providing training, clinical consultation, and clinical case review for members.Essential Functions :Provide APPEALS medical reviews, consultation and clinical review servicesParticipate in peer-to-peer discussionsProvide provider education, training, data sharing, performance evaluations and orientation to the planConduct clinical reviews for designated CareSource members as requestedProvide physician review for clinical appeals casesParticipate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concernsParticipate in development of policies and proceduresParticipates in quality improvement initiatives, case management activities and member safety activities (i.e.incident managementProvide cross-coverage for other Medical Directors and / or markets, as needed.Weekend call in rotation with other medical directors.Oversight and quality improvement activities associated with case management activitiesAssist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriateParticipate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standardsParticipate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiativesCollaborate with market / product leaders to help define market strategyCommunity collaborative participationSupport of regulatory and accreditation functions (eg.CMS, State, NCQA and URAC) and compliance for all programsPerform any other job related instructions, as requestedEducation and Experience :Completion of an accredited Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic (DO) medicine is requiredSuccessful completion of a residency training program, preferably in primary care is requiredMinimum of five (5) years of clinical practice experience is requiredManaged care medical review / medical director experience and experience with appeals are preferredCompetencies, Knowledge and Skills :Basic Microsoft Word skillsExcellent communication skills, both written and oralAbility to work well independently and within a team environmentAbility to create strong relationships with Providers and MembersHigh ethical standardsAttention to detailCritical listening and systematic thinking skillsAbility to maintain confidentiality and act in the company's best interestAbility to act with diplomacy and sensitivity to cultural diversityDecision making / problem solving skillsConflict resolution skillsStrong sense of mission and commitment of time, effort and resources to the betterment of the communities servedLicensure and Certification :Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements is requiredWillingness to acquire additional licenses as needed per regulatory / contractual requirements, with organizational support and fundingBoard Certification, preferably in primary care specialty is requiredRe-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer)MCG Certification is required or must be obtained within six (6) months of hire and is fundedWorking Conditions :General office environment; may be required to sit or stand for extended periods of timeMay be required to work evenings / weekendsMay be required to travel to fulfill duties of positionCompensation Range :191,400.00 - $334,900.00 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.In addition to base compensation, you may qualify for a bonus tied to company and individual performance.We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.Compensation Type :SalaryCompetencies :Create an Inclusive Environment - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the BusinessThis job description is not all inclusive.CareSource reserves the right to amend this job description at any time.CareSource is an Equal Opportunity Employer.We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.LI-SW2. Experience: 12 years required