Regional Vice President overseeing account management and clinical guidance for national clients at Elevance Health. Collaborating with sales and account management teams to enhance healthcare quality and outcomes.
About the role
- Medical Director role supporting staff with training and clinical review at CareSource. Overseeing quality improvement and compliance functions alongside developing care standards.
Responsibilities
- The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members.
- 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
- Collaborate with market/product leaders to help define market strategy
- Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
- Perform any other job related instructions, as requested
Requirements
- 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, 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
- 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
- MCG Certification is required or must be obtained within six (6) months of hire
Benefits
- bonuses tied to company and individual performance
- substantial and comprehensive total rewards package
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