Job Summary:
The Medical Director, Ohio Market is responsible for participating in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards.
Essential Functions:
- Collaborate with market/product leaders to help define market strategy
- Represent CareSource at state and regulatory venues
- Provide prior authorization medical reviews, consultation and clinical review services
- Conduct clinical reviews for designated CareSource members
- Identify utilization management trends and take appropriate action
- Provide provider education, training, data sharing, performance evaluations and orientation to the plan
- Support market provider network development and maintenance
- Support staff by providing training, clinical consultation, and clinical case review for members
- Support program design, development and innovation
- Participate in peer-to-peer discussions
- Participate in the development, implementation and revision of the Quality Improvement Plan and market level quality initiatives
- Community collaborative participation
- Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
- Participate in development of policies and procedures
- Provide cross-coverage for other Medical Directors and/or markets, as needed
- Clinical Appeals
- Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
- 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 is required
- Minimum of five (5) years of clinical practice experience in assigned area of specialty 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 state of practice as necessary to meet regulatory requirements is required
- Board Certification is required
- Re-certification, as required by specialty board, must be maintained
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
- May be required to work evenings/weekends
- May be required to travel to fulfill duties of position
Compensation 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 (hourly/salary):
Salary
Organization Level Competencies
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 inclusive environment that welcomes and supports individuals of all backgrounds.
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