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
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