CareSource
Medical Director (REMOTE Appeals Medical Director – Eastern Standard Time (EST)
CareSource, Columbus, Ohio, United States
Medical Director (REMOTE Appeals Medical Director – Eastern Standard Time (EST) Main Work Hours, Managed Care Experience/Appeals Experience Preferred) - R10088
Join to apply for the
Medical Director (REMOTE Appeals Medical Director – Eastern Standard Time (EST) Main Work Hours, Managed Care Experience/Appeals Experience Preferred) - R10088
role at
CareSource Medical Director (REMOTE Appeals Medical Director – Eastern Standard Time (EST) Main Work Hours, Managed Care Experience/Appeals Experience Preferred) - R10088
6 days ago Be among the first 25 applicants Join to apply for the
Medical Director (REMOTE Appeals Medical Director – Eastern Standard Time (EST) Main Work Hours, Managed Care Experience/Appeals Experience Preferred) - R10088
role at
CareSource Get AI-powered advice on this job and more exclusive features. Job Summary
The Medical Director is responsible for appeals medical necessity determinations, for supporting staff by providing training, clinical consultation, and clinical case review for members. Job Summary
The Medical Director is responsible for appeals medical necessity determinations, for supporting staff by providing training, clinical consultation, and clinical case review for members.
Essential Functions
Provide APPEALS medical reviews, consultation and clinical review services Participate in peer-to-peer discussions Provide provider education, training, data sharing, performance evaluations and orientation to the plan Conduct clinical reviews for designated CareSource members as requested Provide physician review for clinical appeals cases Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns Participate in development of policies and procedures Participates in quality improvement initiatives, case management activities and member safety activities (i.e. incident management Provide cross-coverage for other Medical Directors and/or markets, as needed. Weekend call in rotation with other medical directors. Oversight and quality improvement activities associated with case management activities Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate 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 development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives Collaborate with market/product leaders to help define market strategy Community collaborative participation Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs Perform any other job related instructions, 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 and experience with appeals are 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 Willingness to acquire additional licenses as needed per regulatory / contractual requirements, with organizational support and funding Board Certification, preferably in primary care specialty is required Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer) MCG Certification is required or must be obtained within six (6) months of hire and is funded
Working Conditions
General office environment; may be required to sit or stand for extended periods of time May be required to work evenings/weekends May be required to travel to fulfill duties of position
Compensation Range
$191,400.00 - $334,900.00 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
Salary
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.
Seniority level
Seniority level Director Employment type
Employment type Full-time Job function
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Join to apply for the
Medical Director (REMOTE Appeals Medical Director – Eastern Standard Time (EST) Main Work Hours, Managed Care Experience/Appeals Experience Preferred) - R10088
role at
CareSource Medical Director (REMOTE Appeals Medical Director – Eastern Standard Time (EST) Main Work Hours, Managed Care Experience/Appeals Experience Preferred) - R10088
6 days ago Be among the first 25 applicants Join to apply for the
Medical Director (REMOTE Appeals Medical Director – Eastern Standard Time (EST) Main Work Hours, Managed Care Experience/Appeals Experience Preferred) - R10088
role at
CareSource Get AI-powered advice on this job and more exclusive features. Job Summary
The Medical Director is responsible for appeals medical necessity determinations, for supporting staff by providing training, clinical consultation, and clinical case review for members. Job Summary
The Medical Director is responsible for appeals medical necessity determinations, for supporting staff by providing training, clinical consultation, and clinical case review for members.
Essential Functions
Provide APPEALS medical reviews, consultation and clinical review services Participate in peer-to-peer discussions Provide provider education, training, data sharing, performance evaluations and orientation to the plan Conduct clinical reviews for designated CareSource members as requested Provide physician review for clinical appeals cases Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns Participate in development of policies and procedures Participates in quality improvement initiatives, case management activities and member safety activities (i.e. incident management Provide cross-coverage for other Medical Directors and/or markets, as needed. Weekend call in rotation with other medical directors. Oversight and quality improvement activities associated with case management activities Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate 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 development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives Collaborate with market/product leaders to help define market strategy Community collaborative participation Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs Perform any other job related instructions, 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 and experience with appeals are 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 Willingness to acquire additional licenses as needed per regulatory / contractual requirements, with organizational support and funding Board Certification, preferably in primary care specialty is required Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer) MCG Certification is required or must be obtained within six (6) months of hire and is funded
Working Conditions
General office environment; may be required to sit or stand for extended periods of time May be required to work evenings/weekends May be required to travel to fulfill duties of position
Compensation Range
$191,400.00 - $334,900.00 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
Salary
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.
Seniority level
Seniority level Director Employment type
Employment type Full-time Job function
Job function Health Care Provider Industries Insurance Referrals increase your chances of interviewing at CareSource by 2x Get notified about new Medical Director jobs in
Ohio, United States . Medical Director (REMOTE Appeals Medical Director – Eastern Standard Time (EST) Main Work Hours, Managed Care Experience/Appeals Experience Preferred) (Open)
Physician: Medical Director for MedSpas (OH)
Associate Director, Health Systems (OH-MI)
Cleveland, OH $132,500.00-$240,000.00 2 weeks ago Remote Medical Director- Missouri- Ohio-Kansas
Director, Portfolio Management AtHome Solutions (Urology/Ostomy/Wound Care)
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Remote Medical Director - Missouri - Ohio - Kansas
Mostly Remote-Community Medical Director-Physician-Must live near NE Ohio
Ohio, United States $95,000.00-$175,700.00 9 hours ago Senior Medical Editor and Project Manager - Cleveland Clinic Journal of Medicine
Nurse Practitioner - Advanced Illness Management
Nurse Practitioner - Advanced Illness Management
Hamilton County, OH $110,000.00-$118,000.00 1 week ago Dayton, OH $96,390.00-$120,490.00 4 months ago Dayton, OH $96,390.00-$120,490.00 1 week ago Hamilton County, OH $110,000.00-$118,000.00 2 weeks ago Psychiatric Nurse Practitioner (PMHNP) - Remote
Ohio, United States $125,000.00-$135,000.00 2 weeks ago Bilingual (Spanish) APP - Virtual Urgent Care (overnights)
Sr Specialist, Provider Contracts (Remote)
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr