Job Description
Job Summary: The Medical Director, Ohio Market is responsible for participating in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards. Essential Functions: Collaborate with market/product leaders to help define market strategy Represent CareSource at state and regulatory venues Provide prior authorization medical reviews, consultation and clinical review services Conduct clinical reviews for designated CareSource members Identify utilization management trends and take appropriate action Provide provider education, training, data sharing, performance evaluations and orientation to the plan Support market provider network development and maintenance Support staff by providing training, clinical consultation, and clinical case review for members Support program design, development and innovation Participate in peer-to-peer discussions Participate in the development, implementation and revision of the Quality Improvement Plan and market level quality initiatives Community collaborative participation Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns Participate in development of policies and procedures Provide cross-coverage for other Medical Directors and/or markets, as needed Clinical Appeals Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs 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 is required Minimum of five (5) years of clinical practice experience in assigned area of specialty is required Managed care medical review/medical director experience is preferred Bachelor's or Master's degree in Business Administration, Operational E
