Medical Management Director - CSMV(Managed Care & TRICARE Experience Preferred)

Job description

CareSource Military & Veterans (CSMV) is dedicated to improving health care access and delivery for veterans and military families in service to our nation. Job Summary: The Medical Management Director - CSMV is responsible for leading CareSource Military & Veterans' integrated medical management model, including Utilization Management (UM), Case Management (CM), Behavioral Health (BH), Population Health (PH), Clinical Quality Management (CQM), and Pharmacy Management. This role ensures day-to-day operational compliance with TRICARE requirements and reporting obligations, drives high-quality and cost-effective care, reduces unwarranted variation and waste, and supports reduction in Total Cost of Care (TCOC) for the TRICARE Prime Competitive Plans Demonstration. Essential Functions: - Provide strategic and operational leadership for the Medical Management function across UM, CM, BH, PH, CQM, and Pharmacy. - Oversee utilization management activities, including prospective, concurrent, and retrospective review of beneficiary care. - Oversee prior authorization processes, benefit and service determinations, and inpatient and emergency department concurrent review and census management....