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Company
Name
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Care
Source
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Industry
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Hospital
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Job
Functional Area
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Medicine
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Job
Title
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Medical
Director ICDS
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Job
position
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1
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Job
Type
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Permanent
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Job
Location
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230 N Main St, Dayton, OH 45402, United States
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Minimum Education
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Completion of a Medical Degree program as a
medical doctor (MD) or Doctor of Osteopathic (DO)
Successful completion
of residency training program, preferably in primary care.
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Minimum
Experience
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Minimum five (5) years of clinical practice
experience is required
Managed Care Medical
review/medical director experience is preferred
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Job
Description
The Medical Director provides day-to-day medical review, care
management support and consulting services that pertain to clinical programs
and activities for CareSource. The primary role of the Medical Director
will be to facilitate the delivery of healthcare services for members by
building strong partnerships between Humana/CareSource and its providers and
supporting the patient/physician relationship. The Medical Director will
be a key member of the senior management team, will be charged with clinical
oversight of health plan quality, and will participate with the medical
management team to provide certain care management and utilization review needs
for the plan. The Medical Director will establish clear lines of
communication with physicians and other providers and promote sound principles
of managed care. This position is integral to furthering
relationships with the medical community that are based on a common mission and
shared values.
Essential Functions
- Support care management staff by providing clinical consultation and medical decision making for determination of medical necessity reviews and provide clinical case review and direction for members (all ICDS members receive care management). Support program design and development.
- Conduct peer clinical reviews, working in conjunction with care management nurses and staff and participate in peer-to-peer discussions. Peer to peer discussions may involve medical management, pharmacy and care management reviews for both NF-LOC and non NF-LOC members.
- Work with the Director of Provider Relations to facilitate provider recruitment activities, and where appropriate provide education, training and orientation to the Plan.
- Participate in provider performance evaluations; identify utilization management trends for over/under utilization and take corrective action.
- Participate in the development, implementation and revision of the Quality Improvement Plan.
- Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards.
- Participate in the identification, development and revision of comprehensive clinical assessment tools and integrated clinical edit capabilities within CareSource care management systems.
- Participate in the development of ICDS risk adjustment strategy, tools and practices.
- Contribute to the development, implementation and revision of clinical care standards, practice/utilization guidelines, and transitions coordination protocols for those services delivered to LTCSS (institutionalized) and HCBS waiver participants.
- Ensure processes are in place for confidentiality of medical records, client information and treatment.
- Represent CareSource at state, regulatory, medical director and other meetings as appropriate.
- Participate in the ongoing review of high-risk care management scenarios and provide appropriate recommendations to the care management team.
- Participate in the review and evaluation of ICDS member Protection from Harm (PFH) reportable incidents. This to include individual case review as needed, as well as the evaluation of overall trends/patterns in member health and safety incidents and associated mitigation strategies.
- Participate in evaluation and investigation of cases of suspected fraud and abuse as requested.
- Participate in on-site provider audits/reviews as needed.
- Participate in development of policies and procedures to improve the review process and drive consistency.
- Develop, revise and review Medical Policy Statements as appropriate in conjunction with input from the Senior Medical Director(s) and CMO.
- Participate in and lead committees and CareSource programs as assigned by the Senior Medical Director and/or Chief Medical Officer (CMO).
- Provide Quality of Care reviews working with QI and care management nurses and staff.
- Investigate potential Quality of Care concerns identified in the medical review process.
- Provide clinical training and education to nurses, staff as appropriate to improve medical, and Quality of Care processes.
- Develop and implement targeted health improvement/management initiatives for CareSource members.
- Perform any other job related instructions as requested, with reasonable accommodation.
Minimum Qualifications:
Education:
- Completion of a Medical Degree
program as a medical doctor (MD) or Doctor of Osteopathic (DO) is
required
- Successful completion of
residency training program, preferably in primary care is require
Experience:
- Minimum five (5) years of
clinical practice experience is required
- Managed Care Medical
review/medical director experience is preferred
Technical Skills:
- Basic Microsoft Word skills
Knowledge, Skills, and Abilities:
- Excellent communication skills,
both written and oral
- Prior supervisory skills
- Ability to work well
independently and within a team environment
- Attention to detail
- Critical listening and
systematic thinking skills
- Ability to maintain
confidentiality and act in the company’s best interest
- Oral, written, and
interpersonal communication skills
- Leadership experience and
skills
- Ability to act with diplomacy
and sensitivity to cultural diversity
- Strategic management skills
- Decision making/problem solving
skills
- Conflict resolution skills
- Ability to analyze healthcare
data from a variety of sources to evaluate physician practice patterns
- Strong sense of mission and
commitment of time, effort and resources to the betterment of the
communities served
Certification/Licensure:
- Licensed 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 as required by
specialty board must be maintained except where extenuating circumstances
contribute to a temporary lapse (less than 1 year and approved by CMO) is
required
