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Enterprise Medical Director, Post-Service Review, Medical Claims Review
CareSource. Develop, implement, and revise corporate-level clinical care standards, practice guidelines, the Quality Improvement Plan, and quality initiatives .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical care standards, quality improvement initiatives, and regulatory compliance, with a strong focus on provider education and operational leadership. Possesses the ability to analyze healthcare data and lead clinical review processes to ensure high-quality care and adherence to standards.
Highest-signal resume keywords
Medical Degree (MD or DO)Clinical Practice Experience (5+ Years)Managed Care Medical Review ExperienceBoard Certification in Primary Care SpecialtyMCG Certification
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Care Standards DevelopmentQuality Improvement Plan ImplementationUtilization Management AnalysisClinical Documentation EvaluationMedical Review ServicesData Analysis of Healthcare TrendsPolicy and Procedure DevelopmentClinical Case ReviewPrior Authorization Medical ReviewsOperational Leadership
Soft Skills
Excellent Written and Oral CommunicationRelationship Building with Providers and MembersAttention to DetailDecision-Making SkillsConflict Resolution Skills
Tools & Technologies
Microsoft Word
Certifications & Qualifications
Current Medical LicenseBoard CertificationMCG Certification
Industry Keywords
Regulatory ComplianceAccreditation StandardsCMS RequirementsNCQA StandardsURAC ComplianceHealthcare AdministrationOperational ExcellenceClinical Audit MethodologiesPayment Integrity ActivitiesQuality-of-Care Concerns
About the role
Key responsibilities & impact- Develop, implement, and revise corporate-level clinical care standards, practice guidelines, the Quality Improvement Plan, and quality initiatives
- Develop policies and procedures
- Provide Medical Director operational leadership and Medical Economics Analytics
- Identify utilization management trends and take appropriate action
- Support regulatory, accreditation, and compliance functions for CMS, state, NCQA, and URAC requirements
- Provide staff 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
- Evaluate and investigate suspected 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
- Handle clinical appeals
- Collaborate with market and product leaders to define market strategy
- Provide oversight and direction to assigned managers and associates
- Serve as clinical leader for physician-led post-service audits and payment integrity activities involving high-dollar claims, HACs, quality-of-care concerns, and claims requiring medical judgment
- Evaluate medical records, clinical documentation, claims data, and audit findings for medical necessity, clinical appropriateness, quality of care, and payment recovery opportunities
- Partner with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics on MCR program development, implementation, governance, and continuous improvement
- Lead the MCR operating model, Medical Director review team, clinical audit methodologies, physician review standards, and capability expansion
- Support provider engagement, audit findings, disputes, appeals, and related clinical review activities
- Perform other duties as requested
Requirements
What you’ll need- Completion of an accredited Medical Degree program as an MD or DO 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
- Basic Microsoft Word skills
- Excellent written and oral communication skills
- Ability to work 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 to communities served
- Ability to analyze healthcare data from a variety of sources to evaluate physician practice patterns
- Leadership experience and skills
- 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 must be maintained as required by the specialty board
- MCG Certification is required or must be obtained within six (6) months of hire
Benefits
Comp & perks- Bonus tied to company and individual performance may be available
- Comprehensive total rewards package
- Employee total well-being support