Medical Director

Job Summary

The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members.

Essential Functions

* Provide clinical review services as directed * 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 (i.e. incident management * 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 as appropriate * 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 * Community collaborative participation * Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs * Perform any other job related duties as requested.

Education and Experience

* Doctor of Osteopathic Medicine (DO) required or * Medical Doctor (MD) required * Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is