Medical Director (REMOTE Appeals Medical Director - Pacific Standard Time, Managed Care Experience, Family Medicine and Appeals Experience Preferred")

📋 Description

• • As a Medical Director at CareSource, you will play a pivotal role in ensuring the highest standards of clinical care and operational excellence within our managed care environment. This remote position offers a unique opportunity to leverage your extensive medical expertise to support staff, conduct critical clinical reviews, and contribute to the strategic direction of our healthcare services.
• • Your primary responsibility will be to provide essential clinical consultation and case review services, directly impacting member care and staff development. This includes conducting thorough prior authorization medical reviews, ensuring that treatments and services align with established medical necessity criteria and organizational policies.
• • A key aspect of this role involves engaging in peer-to-peer discussions with other healthcare professionals. This collaborative approach is crucial for resolving complex cases, sharing best practices, and fostering a culture of continuous learning and improvement among the medical team.
• • You will be instrumental in provider education, training, and data sharing initiatives. By orienting providers to the plan's services and guidelines, you will help to optimize care delivery and ensure adherence to quality standards. This proactive engagement aims to build strong, collaborative relationships with our provider network.
• • The role requires conducting detailed clinical reviews for designated CareSource members, ensuring that all care provided is appropriate, effective, and aligned with member needs and plan benefits. This includes providing physician review for clinical appeals cases, offering expert medical judgment to resolve disputes and ensure fair outcomes.
• • You will actively participate in the evaluation and investigation of cases suspected of fraud, abuse, or quality of care concerns. Your clinical insights will be vital in identifying potential risks and implementing corrective actions to protect members and the integrity of our healthcare system.
• • Contributing to the development of policies and procedures is a significant part of this position. You will help shape the clinical framework of CareSource, ensuring that our operational guidelines are evidence-based, compliant, and promote optimal patient outcomes.
• • Your involvement in quality improvement initiatives, case management activities, and member safety programs (such as incident management) will directly enhance the overall quality of care delivered. This includes identifying areas for improvement and implementing strategies to achieve them.
• • To ensure comprehensive support, you will provide cross-coverage for other Medical Directors and/or markets as needed, demonstrating flexibility and a commitment to team success. This ensures continuity of care and operational efficiency across the organization.
• • You will also be responsible for the oversight and quality improvement activities associated with case management, ensuring that our case managers are equipped with the necessary clinical guidance and support to effectively manage member care plans.
• • Assisting in the review of utilization data is another critical function. You will identify variances in treatment patterns, providing valuable feedback and education to both Medical Care Plan (MCP) staff and providers to promote evidence-based practices and resource stewardship.
• • A significant contribution will be in the development, implementation, and revision of clinical care standards and practice guidelines. This ensures compliance with nationally accepted quality standards and promotes consistent, high-quality care across all services.
• • You will also participate in the development, implementation, and revision of the Quality Improvement Plan and corporate-level quality initiatives, driving strategic efforts to elevate the standard of care and member satisfaction.
• • Collaboration with market and product leaders is essential to help define market strategy, ensuring that clinical expertise informs business decisions and service offerings.
• • Community collaborative participation is encouraged, allowing you to represent CareSource in broader healthcare initiatives and build external partnerships.
• • You will provide crucial support for regulatory and accreditation functions, including those related to CMS, State, NCQA, and URAC, ensuring compliance for all programs and maintaining our organizational accreditations.
• • This role demands a proactive, analytical, and collaborative approach, with a strong commitment to improving the health and well-being of the communities we serve.