Medical Director at CareSource Management Services LLC — Remote

Job Summary:

The Clinical Appeals Medical Director will perform medical necessity review of appeals, within the organization, ensuring timely, accurate, quality and compliant review of clinical appeals. Administers the decision-making process related to appeals, supports clinical operations, and facilitates communication among stakeholders.

Essential Functions:

• Review and make determinations on complex clinical appeals in accordance with medical guidelines, internal policy, state and regulatory requirements
• Provide clinical expertise and guidance in the evaluation of appeals related to medical necessity and appropriateness of care.
• Collaborated with cross functioning teams including legal, compliance, utilization management and provider relations to ensure consistent, timely and fairness and appeals adjudication
• Support the development and implementation of clinical guidelines and protocols to standardize the appeals process and improve outcomes.
• Serve as a liaison between the organization, internal and external stakeholders.
• Participate in quality assurance initiatives to enhance the overall effectiveness of the clinical appeals process.
• Stay current with industry trends, regulations, and best practices related to clinical appeals and managed care.
• Maintain required state licensure and board certification status.
• Perform any other job related duties as requested.

Education and Experience:

• Doctoral Medical degree (MD or DO) from an accredited institution. required
• Bachelor's or Master's degree in Business Administration, Healthcare Administration or Medical Management preferred
• Successful completion of a residency training program required
• Five (5) years Clinical practice experience required
• Five (5) years Managed care medical review/medical director experience preferred

Competencies, Knowledge and Skills:

• Excellent verbal and written communication skills
• Clinical decision making
• Healthcare policy knowledge
• Appeals processing
• Stakeholder communication
• Medical expertise
• Outcomes improvement
• Policy adherence
• Familiarity with medical necessity criteria and clinical guidelines.

Licensure and Certification:

• Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements required
• Board certification in a relevant clinical specialty required
• Re-certification as required by specialty board must be maintained
• MCG Certification is required or must be obtained within six 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 additional hours outside normal business hours including evenings, weekends and holidays
• Ability to travel as required by the needs of the department.

Compensation Range:

$195,200.00 - $341,600.00CareSource 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):

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

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Brand=CareSource