Remote Medical Director, Grievances & Appeals

Job Summary:

Medical Directors support CareSource staff by providing training, clinical consultation, and clinical case review for members.

Essential Functions:

• Support staff by providing training, clinical consultation, and clinical case review for members
• Participate in peer-to-peer discussions
• Provide provider education, training, data sharing, performance evaluations and orientation to the plan
• 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
• Provide prior authorization medical reviews, consultation and clinical review services
• Conduct clinical reviews for designated CareSource members
• Clinical Appeals
• Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs 

• Managed care medical review/medical director experience is required.

• Managed care appeals determinations experience with multiple lines of business (e.g. Medicaid, Medicare, Marketplace) is required.

• 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, preferably in primary care is required
• Minimum of five (5) years of clinical practice experience 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

Licensure and Certification:

• Current, unrestricted license to practice medicine in  state of practice as necessary to meet regulatory requirements is required
• Board Certification, preferably in primary care specialty 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
• Ability to travel as required by the needs of the business

Compensation Range:

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.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.