Medical Director(Must Live In Massachusetts)

📋 Description

• • The Medical Director at CareSource Management Group Company plays a critical role in ensuring high-quality, clinically sound healthcare delivery by providing expert medical oversight, training, and consultation to support staff, providers, and members across Massachusetts. This position is essential for maintaining compliance with regulatory standards, driving quality improvement initiatives, and safeguarding member safety through rigorous clinical review and evidence-based decision-making.
• • Day-to-day responsibilities include conducting prior authorization medical reviews and clinical case evaluations for CareSource members, participating in peer-to-peer discussions with providers to resolve clinical discrepancies, and delivering physician reviews for clinical appeals cases to ensure fair and medically appropriate outcomes. The Medical Director also provides provider education and training sessions, shares performance data, and orients new providers to the plan’s clinical standards and procedures.
• • Additional daily functions involve participating in the evaluation and investigation of suspected fraud, abuse, or quality-of-care concerns, contributing to the development and revision of clinical care standards and practice guidelines in alignment with nationally accepted benchmarks, and supporting quality improvement initiatives and case management activities aimed at enhancing member safety and outcomes.
• • The Medical Director collaborates closely with market and product leaders to help define regional market strategy, engages in community collaborative efforts to strengthen public health partnerships, and supports regulatory and accreditation functions for programs overseen by CMS, state agencies, NCQA, and URAC, ensuring full compliance across all operations.
• • The role includes providing cross-coverage for other Medical Directors or markets as needed, assisting in the analysis of utilization data to identify variances in care patterns, and delivering targeted feedback and education to both MCP staff and providers to promote efficient, appropriate care delivery.
• • The Medical Director actively participates in the development, implementation, and revision of the Quality Improvement Plan and corporate-level quality initiatives, contributing to systemic improvements in healthcare delivery and organizational performance.
• • About the team or company: CareSource Management Group Company is a mission-driven, nonprofit healthcare organization dedicated to improving access to high-quality care for underserved populations. As an Equal Opportunity Employer, CareSource fosters a culture of belonging, innovation, and accountability, where employees are empowered to make meaningful impacts on community health and well-being.
• • What the person can learn or achieve in this role: The Medical Director will have the opportunity to influence clinical policy at a systemic level, gain deep experience in managed care operations and healthcare administration, and lead quality and safety initiatives that directly affect thousands of members. This role offers significant professional growth in clinical leadership, healthcare strategy, and organizational influence within a respected national managed care organization.