Medical Director

🔥 0 minutes 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 subject matter expertise and medical leadership for utilization management, care management, and quality-of-care programs for infant and neonatology services • Work with Vice Presidents of Utilization Management, Care Management, and Medical Directors to achieve utilization, care management, and quality-of-care objectives for newborn and infant members and their mothers • Provide staff training, clinical consultation, and clinical case review • Perform 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 physician review for clinical appeal cases • Evaluate and investigate suspected fraud, abuse, and quality-of-care concerns • Participate in quality improvement, case management, and member safety initiatives • Oversee and improve case management activities • Review utilization data, identify pattern variances, and provide feedback and education to plan staff and providers • Develop, implement, and revise clinical care standards and practice guidelines in compliance with nationally accepted quality standards • Develop, implement, and revise the Quality Improvement Plan and corporate quality initiatives • Collaborate with market and product leaders to define market strategy • Liaise with community-based organizations and health systems regarding neonatal prevention, care coordination, and care management • Support regulatory, accreditation, and compliance functions, including CMS, state requirements, NCQA, and URAC • Participate in Utilization Management rounds and educate UM staff on NICU utilization management, levels of care, and quality of care • Develop and improve transitions of care for NICU members graduating from the NICU • Create formal clinical policy for NICU and post-NICU transitions and care management • Perform other duties as requested

🎯 Requirements

• Completion of an accredited Medical Degree program as an MD or DO is required • Successful completion of a pediatrics residency and neonatology fellowship, or equivalent experience, is required • Minimum of five (5) years of clinical practice experience is required • Current, unrestricted license to practice medicine in the state of practice, as required by regulatory requirements • Board certification in Pediatrics is required, preferably in a primary care specialty • Board certification in Neonatology is required • Specialty board re-certification must be maintained • 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 • Willingness to work evenings/weekends as required • Willingness to travel as required

🏖️ Benefits

• Bonus tied to company and individual performance • Comprehensive total rewards package • Employee total well-being support • Equal opportunity and belonging-focused workplace