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

Job Summary:

The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members.

Essential Functions:

• Provide clinical review services as directed
• 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
• 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 duties as requested.

Education and Experience:

• Doctor of Osteopathic Medicine (DO) required or
• Medical Doctor (MD) required
• Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is preferred
• Successful completion of a residency training program, preferably in primary care is required
• Five (5) years of clinical practice experience required
• Managed care medical review/medical director experience 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 required
• Board Certification, preferably in primary care specialty required
• Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer) required
• MCG Certification is required or must be obtained within six (6) months of hire required

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• May be required to work evenings/weekends
• Up to 15% (Occasional) travel to attend meetings, trainings, and conferences may be required

For Medical Claims Review (MCR) assignments, the Medical Director serves as the physician reviewer for post-service clinical audits and payment integrity activities involving high-dollar claims, Hospital Acquired Conditions (HACs), quality-of-care concerns, and other claims requiring medical judgment.

The Medical Director is responsible for evaluating medical records, clinical documentation, claims data, and audit findings to determine medical necessity, clinical appropriateness, quality-of-care considerations, and potential payment recovery opportunities.

This role partners closely with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics teams to support physician-led post-service review activities.  The role also supports provider discussions, audit findings, disputes, appeals, and continuous improvement initiatives associated with the enterprise Medical Claims Review (MCR) capability.