Enterprise Medical Director

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