Medical Director

Job description

Job Summary: The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members. Essential Functions: - Provide prior authorization 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 - 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 developmen...