Enterprise Medical Director, Post-Service Review, Medical Claims Review

🔥 14 hours ago

🇺🇸 United States – Remote

💵 $195.2k - $341.6k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • 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.

📋 Description

• Develop, implement, and revise corporate-level clinical care standards, practice guidelines, the Quality Improvement Plan, and quality initiatives • Develop policies and procedures • Provide Medical Director operational leadership and Medical Economics Analytics • Identify utilization management trends and take appropriate action • Support regulatory, accreditation, and compliance functions for CMS, state, NCQA, and URAC requirements • Provide staff 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 • Evaluate and investigate suspected 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 • Handle clinical appeals • Collaborate with market and product leaders to define market strategy • Provide oversight and direction to assigned managers and associates • Serve as clinical leader for physician-led post-service audits and payment integrity activities involving high-dollar claims, HACs, quality-of-care concerns, and claims requiring medical judgment • Evaluate medical records, clinical documentation, claims data, and audit findings for medical necessity, clinical appropriateness, quality of care, and payment recovery opportunities • Partner with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics on MCR program development, implementation, governance, and continuous improvement • Lead the MCR operating model, Medical Director review team, clinical audit methodologies, physician review standards, and capability expansion • Support provider engagement, audit findings, disputes, appeals, and related clinical review activities • Perform other duties as requested

🎯 Requirements

• Completion of an accredited Medical Degree program as an MD or DO 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 • Basic Microsoft Word skills • Excellent written and oral communication skills • Ability to work 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 to communities served • Ability to analyze healthcare data from a variety of sources to evaluate physician practice patterns • Leadership experience and skills • Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements is required • Board Certification, preferably in primary care specialty, is required; re-certification must be maintained as required by the specialty board • MCG Certification is required or must be obtained within six (6) months of hire

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Employee total well-being support