Job Summary: The Medical Director provides day-to-day medical review, care management support and consulting services that pertain to clinical programs and activities for CareSource. The primary role of the Medical Director will be to facilitate the delivery of healthcare services for members by building strong partnerships between Humana/CareSource and its providers and supporting the patient/physician relationship. The Medical Director will be a key member of the senior management team, will be charged with clinical oversight of health plan quality, and will participate with the medical management team to provide certain care management and utilization review needs for the plan. The Medical Director will establish clear lines of communication with physicians and other providers and promote sound principles of managed care. This position is integral to furthering relationships with the medical community that are based on a common mission and shared values.
· Support care management staff by providing clinical consultation and medical decision making for determination of medical necessity reviews and provide clinical case review and direction for members (all ICDS members receive care management). Support program design and development.
- Conduct peer clinical reviews, working in conjunction with care management nurses and staff and participate in peer-to-peer discussions. Peer to peer discussions may involve medical management, pharmacy and care management reviews for both NF-LOC and non NF-LOC members.
- Work with the Director of Provider Relations to facilitate provider recruitment activities, and where appropriate provide education, training and orientation to the Plan.
- Participate in provider performance evaluations; identify utilization management trends for over/under utilization and take corrective action.
- Participate in the development, implementation and revision of the Quality Improvement Plan.
- Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards.
- Participate in the identification, development and revision of comprehensive clinical assessment tools and integrated clinical edit capabilities within CareSource care management systems.
- Participate in the development of ICDS risk adjustment strategy, tools and practices.
- Contribute to the development, implementation and revision of clinical care standards, practice/utilization guidelines, and transitions coordination protocols for those services delivered to LTCSS (institutionalized) and HCBS waiver participants.
- Ensure processes are in place for confidentiality of medical records, client information and treatment.
- Represent CareSource at state, regulatory, medical director and other meetings as appropriate.
- Participate in the ongoing review of high-risk care management scenarios and provide appropriate recommendations to the care management team.
- Participate in the review and evaluation of ICDS member Protection from Harm (PFH) reportable incidents. This to include individual case review as needed, as well as the evaluation of overall trends/patterns in member health and safety incidents and associated mitigation strategies.
- Participate in evaluation and investigation of cases of suspected fraud and abuse as requested.
- Participate in on-site provider audits/reviews as needed.
- Participate in development of policies and procedures to improve the review process and drive consistency.
- Develop, revise and review Medical Policy Statements as appropriate in conjunction with input from the Senior Medical Director(s) and CMO.
- Participate in and lead committees and CareSource programs as assigned by the Senior Medical Director and/or Chief Medical Officer (CMO).
- Provide Quality of Care reviews working with QI and care management nurses and staff.
- Investigate potential Quality of Care concerns identified in the medical review process.
- Provide clinical training and education to nurses, staff as appropriate to improve medical, and Quality of Care processes.
- Develop and implement targeted health improvement/management initiatives for CareSource members.
- Perform any other job related instructions as requested, with reasonable accommodation.
- Minimum five (5) years of clinical practice experience is required
- Managed Care Medical review/medical director experience is preferred
Knowledge, Skills, and Abilities:
- Basic Microsoft Word skills
- Excellent communication skills, both written and oral
- Prior supervisory skills
- Ability to work well independently and within a team environment
- Attention to detail
- Critical listening and systematic thinking skills
- Ability to maintain confidentiality and act in the company’s best interest
- Oral, written, and interpersonal communication skills
- Leadership experience and skills
- Ability to act with diplomacy and sensitivity to cultural diversity
- Strategic management skills
- Decision making/problem solving skills
- Conflict resolution skills
- Ability to analyze healthcare data from a variety of sources to evaluate physician practice patterns
- Strong sense of mission and commitment of time, effort and resources to the betterment of the communities served
- Completion of a Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic (DO) is required
- Successful completion of residency training program, preferably in primary care is required
· Board Certification, preferably in primary care specialty is required
- Licensed to practice medicine in state of practice as necessary to meet regulatory requirements is required
· Re-certification as required by specialty board must be maintained except where extenuating circumstances contribute to a temporary lapse (less than 1 year and approved by CMO) is required
About the Organization
CareSource is the 2nd largest Medicaid managed health care plan in the country, and our strength lies in our experience. CareSource provides a full spectrum of services for the administration of public-sector health care programs, serving more than 900,000 Medicaid consumers in Ohio and Michigan.
Our health plans are founded on the principles of quality and service delivered with compassion and a thorough understanding of Medicaid, Medicare, and the associated regulatory environments. We offer a unique approach to managed care through the process efficiencies and value-added benefits we offer to our members and the health care providers we partner with to serve them. As a managed health care organization, CareSource focuses on prevention with a goal of improving member health and the quality and accessibility of health care services for Medicaid consumers. CareSource assists in the coordination of member care by partnering with a defined network of participating doctors, hospitals and other health care providers.
CareSource is an equal opportunity employer that offers a drug and tobacco free environment and a competitive compensation and benefits package to full-time and part-time employees who work at least 24 hours per week.
The benefits package includes:
• Health, dental and vision insurance
• Flexible spending accounts (health and dependent care)
• Life insurance
• Accidental death and dismemberment insurance
• Short- and long-term disability insurance
• 401(k) retirement plan
• Liberal paid personal time to be used on a discretionary basis for sick leave or as scheduled time off
• Eight paid holidays and a floating holiday
• Educational reimbursement
For more information about CareSource, please see About Us on our website, www.caresource.com.
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