Medical Director, Post-Service Review, Medical Claims Review

🔥 13 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

• Provide clinical review services and clinical case review for members • 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 • Provide physician review for clinical appeals cases • Evaluate and investigate suspected fraud, abuse, and quality-of-care concerns • Develop policies, procedures, clinical care standards, practice guidelines, Quality Improvement Plans, and corporate quality initiatives • Participate in quality improvement, case management, member safety, regulatory, accreditation, and compliance activities • Provide cross-coverage for other Medical Directors and/or markets • Review utilization data to identify pattern variances and provide feedback and education • Collaborate with market and product leaders to define market strategy • Participate in community collaboratives • For MCR assignments, serve as physician reviewer for post-service clinical audits and payment integrity activities involving high-dollar claims, HACs, quality-of-care concerns, and other claims requiring medical judgment • Evaluate medical records, clinical documentation, claims data, and audit findings to determine medical necessity, clinical appropriateness, quality-of-care considerations, and payment recovery opportunities • Partner with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics teams • Support provider discussions, audit findings, disputes, appeals, and continuous improvement initiatives for the enterprise MCR capability • Perform other job-related duties as requested

🎯 Requirements

• Doctor of Osteopathic Medicine (DO) required or Medical Doctor (MD) required • Successful completion of a residency training program, preferably in primary care, is required • Five (5) years of clinical practice experience required • 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 • MCG Certification is required or must be obtained within six (6) months of hire • 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 and problem-solving skills • Conflict resolution skills • Strong sense of mission and commitment to communities served • Managed care medical review/medical director experience preferred • Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is preferred

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Up to 15% travel to attend meetings, trainings, and conferences