Medical Director, Post-Service Review, Medical Claims Review

CareSource

. Provide clinical review services and clinical case review for members .

Posted 9/23/2026full-timeRemote • United StatesLead💰 $195,200 - $341,600 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in clinical review services, provider education, and quality improvement initiatives while maintaining high ethical standards and effective communication with providers and members. Possesses strong decision-making, problem-solving, and conflict resolution skills essential for managing clinical appeals and compliance activities.

Highest-signal resume keywords

Doctor Of Osteopathic Medicine (DO)Medical Doctor (MD)Board Certification In Primary Care SpecialtyMCG CertificationManaged Care Medical Review Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Review ServicesClinical Case ReviewUtilization Data ReviewMedical Necessity EvaluationQuality Improvement PlansClinical Documentation EvaluationPerformance EvaluationsProvider EducationFraud InvestigationAccreditation Compliance

Soft Skills

Excellent Written CommunicationExcellent Oral CommunicationAttention To DetailCritical ListeningConflict Resolution

Tools & Technologies

Microsoft Word

Certifications & Qualifications

Current Unrestricted Medical LicenseBoard CertificationMCG Certification

Industry Keywords

Managed CareQuality Of CareClinical AppealsCase ManagementHealthcare Administration

About the role

Key responsibilities & impact

Provide clinical review services 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
Conduct clinical reviews for designated CareSource members
Provide physician review for clinical appeals cases
Evaluate and investigate suspected fraud, abuse, and quality-of-care concerns
Develop policies, procedures, clinical care standards, practice guidelines, Quality Improvement Plans, and corporate quality initiatives
Participate in quality improvement, case management, member safety, regulatory, accreditation, and compliance activities
Provide cross-coverage for other Medical Directors and/or markets
Review utilization data to identify pattern variances and provide feedback and education
Collaborate with market and product leaders to define market strategy
Participate in community collaboratives
For MCR assignments, serve as physician reviewer for post-service clinical audits and payment integrity activities involving high-dollar claims, HACs, quality-of-care concerns, and other claims requiring medical judgment
Evaluate medical records, clinical documentation, claims data, and audit findings to determine medical necessity, clinical appropriateness, quality-of-care considerations, and payment recovery opportunities
Partner with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics teams
Support provider discussions, audit findings, disputes, appeals, and continuous improvement initiatives for the enterprise MCR capability
Perform other job-related duties as requested

Requirements

What you’ll need

Doctor of Osteopathic Medicine (DO) required or Medical Doctor (MD) required
Successful completion of a residency training program, preferably in primary care, is required
Five (5) years of clinical practice experience required
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
MCG Certification is required or must be obtained within six (6) months of hire
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 and problem-solving skills
Conflict resolution skills
Strong sense of mission and commitment to communities served
Managed care medical review/medical director experience preferred
Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is preferred

Benefits

Comp & perks

Bonus tied to company and individual performance may be available
Comprehensive total rewards package
Up to 15% travel to attend meetings, trainings, and conferences