Medical Director, Ohio Market(Geriatrics, Internal Medicine, Family Practice Preferred)

Stellenbeschreibung:

Job Summary

The Medical Director, Ohio Market is responsible for participating in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards.

Essential Functions

Collaborate with market/product leaders to help define market strategy
Represent CareSource at state and regulatory venues
Provide prior authorization medical reviews, consultation and clinical review services
Conduct clinical reviews for designated CareSource members
Identify utilization management trends and take appropriate action
Provide provider education, training, data sharing, performance evaluations and orientation to the plan
Support market provider network development and maintenance
Support staff by providing training, clinical consultation, and clinical case review for members
Support program design, development and innovation
Participate in peer-to-peer discussions
Participate in the development, implementation and revision of the Quality Improvement Plan and market level quality initiatives
Community collaborative participation
Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
Participate in development of policies and procedures
Provide cross-coverage for other Medical Directors and/or markets, as needed
Clinical Appeals
Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
Perform any other job duties as requested

Education and Experience

Completion of an accredited Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic (DO) medicine is required
Successful completion of a residency training program is required
Minimum of five (5) years of clinical practice experience in assigned area of specialty 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

Competencies, Knowledge and Skills

Basic Microsoft Word skills
Excellent communication skills, both written and oral
Ability to work well 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 of time, effort and resources to the betterment of the communities served
Ability to analyze healthcare data from a variety of sources to evaluate physician practice patterns
Leadership experience and skills

Licensure and Certification

Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements is required
Board Certification is required
Re-certification, as required by specialty board, must be maintained

Working Conditions

General office environment; may be required to sit or stand for extended periods of time
May be required to work evenings/weekends
May be required to travel to fulfill duties of position

Compensation Range

$191,400.00 - $334,900.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well‑being and offer a substantial and comprehensive total rewards package.