Enterprise Medical Director, Post-Service Review & Medical Claims Review (MCR)

Job Summary:

The Enterprise Medical Director is responsible for the development, implementation and revision of corporate level clinical care standards and practice guidelines, ensuring compliance with nationally accepted quality standards.

Essential Functions:

• Development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives
• Development of policies and procedures
• Medical Director Operational leadership, Medical Economics Analytics
• Identify utilization management trends and take appropriate action
• Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
• 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
• 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
• Collaborate with market/product leaders to help define market strategy
• Provides oversight and direction of assigned managers and associates
• 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
• Ability to analyze healthcare data from a variety of sources to evaluate physician practice patterns
• Leadership experience and skills

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
• MCG Certification is required or must be obtained within six (6) months of hire

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

For Medical Claims Review (MCR) assignments, the Enterprise Medical Director serves as the clinical leader for physician-led post-service audits and payment integrity activities involving high-dollar claims, Hospital Acquired Conditions (HACs), quality-of-care concerns, and other claims requiring medical judgment. The Enterprise Medical Director is responsible for evaluating medical records, clinical documentation, claims data, and audit findings to assess medical necessity, clinical appropriateness, quality-of-care considerations, and potential payment recovery opportunities. The role partners closely with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics to support the development, implementation, governance, and continuous improvement of the MCR program. In addition, the Enterprise Medical Director provides leadership for the MCR operating model, Medical Director review team, clinical audit methodologies, physician review standards, and expansion of the capability beyond the initial HAC and high dollar claims proof of concept. The role supports provider engagement, audit findings, disputes, appeals, and related clinical review activities while helping scale MCR as a strategic enterprise payment integrity and clinical audit capability.

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

• Fostering a Collaborative Workplace Culture

• 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 environment of belonging that welcomes and supports individuals of all backgrounds.