Medical Director, Preferred Experience in Managed Care

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November 26

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CareSource

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Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

1001 - 5000 employees

Founded 30+ years

⚕️ Healthcare Insurance

📋 Description

• Provide prior authorization medical reviews, consultation and clinical review services • 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 • 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 • 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 • Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs

🎯 Requirements

• Completion of an accredited Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic (DO) • Successful completion of a residency training program, preferably in primary care • Minimum of five (5) years of clinical practice experience required • Managed care medical review/medical director experience preferred • Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management preferred • Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements • Board Certification, preferably in primary care specialty required • MCG Certification required or must be obtained within six (6) months of hire

🏖️ Benefits

• Comprehensive total rewards package • Bonuses tied to company and individual performance