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Medical Director, Behavioral Health

at CareSource

Posted: 1/28/2020
Job Reference #: *42B2090E9204C226

Job Description

Requisition Number

Post Date

Medical Director, Behavioral Health




Role and Responsibility:

  • Support program design and development
  • Development of policies and procedures
  • Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
  • Provide provider education, training, data sharing, performance evaluations and orientation to the 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 development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives
  • Collaborate with market/product leaders to help define market strategy
  • Community collaborative participation
  • Participate in the evaluation and investigations of cases suspected of 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
  • Identify utilization management trends and take appropriate action
  • Support market provider network development and maintenance
  • Clinical Appeals
  • Participate in peer-to-peer discussions
  • Support staff by providing training, clinical consultation, and clinical case review for members
  • Perform any other job related instructions, as requested


Education / 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, preferably in psychiatry 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

    Required Competencies / Knowledge / Skills:

  • Basic Microsoft Word skills
  • Excellent communication skills, both written and oral
  • Ability to work well 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 of time, effort and resources to the betterment of the communities served
  • Ability to analyze healthcare data from a variety of sources to evaluate physician practice patterns
  • Leadership experience and skills

    Licensure / Certification:

  • Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements is required
  • Board Certification in psychiatry is required
  • Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer)

    Working Conditions:

  • General office environment; required to use general office equipment
  • May be required to work evenings/weekends
  • May be required to travel to fulfill duties of position