Medical Director, Post-Service Review & Medical Claims Review (MCR)

Job Summary:

The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members.

Essential Functions:

Provide clinical review services as directed

Participate in peer-to-peer discussions

Provide provider education, training, data sharing, performance evaluations and orientation to the plan

Conduct clinical reviews for designated CareSource members as requested

Provide physician review for clinical appeals cases

Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns

Participate in development of policies and procedures

Participates in quality improvement initiatives, case management activities and member safety activities (i.e. incident management

Provide cross-coverage for other Medical Directors and/or markets, as needed

Oversight and quality improvement activities associated with case management activities

Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate

Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards

Participate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives

Collaborate with market/product leaders to help define market strategy

Community collaborative participation

Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs

Perform any other job related duties as requested.

Education and Experience:

Doctor of Osteopathic Medicine (DO) required or

Medical Doctor (MD) required

Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is preferred

Successful completion of a residency training program, preferably in primary care is required

Five (5) years of clinical practice experience required

Managed care medical review/medical director experience 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

Licensure and Certification:

Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements required

Board Certification, preferably in primary care specialty required

Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer) required

MCG Certification is required or must be obtained within six (6) months of hire required

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time

May be required to work evenings/weekends

Up to 15% (Occasional) travel to attend meetings, trainings, and conferences may be required

For Medical Claims Review (MCR) assignments, the Medical Director serves as the physician reviewer for post-service clinical audits and payment integrity activities involving high-dollar claims, Hospital Acquired Conditions (HACs), quality-of-care concerns, and other claims requiring medical judgment. The Medical Director is responsible for evaluating medical records, clinical documentation, claims data, and audit findings to determine medical necessity, clinical appropriateness, quality-of-care considerations, and potential payment recovery opportunities. This role partners closely with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics teams to support physician-led post-service review activities. The role also supports provider discussions, audit findings, disputes, appeals, and continuous improvement initiatives associated with the enterprise Medical Claims Review (MCR) capability.

$195,200.00 - $341,600.00 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.

Salary

Organization Level Competencies

- Fostering a Collaborative Workplace Culture - 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. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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