Medical Director, Ohio Market(Geriatrics, Internal Medicine, Family Practice Preferred) - R10269

CareSource is seeking a Medical Director for the Ohio Market, responsible for developing and implementing clinical care standards and ensuring compliance with quality standards. The role involves collaboration with market leaders, clinical reviews, provider education, and participation in quality initiatives.

Responsibilities:

• 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

Requirements:

• 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
• 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
• 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
• 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