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Job Summary
The Enterprise Medical Director is responsible for the development, implementation and revision of corporate level clinical care standards and practice guidelines, ensuring compliance with nationally accepted quality standards.
Essential Functions Development, implementation and revision of the Quality Improvement Plan and corporate‑level quality initiatives Development of policies and procedures Medical Director operational leadership, medical economics analytics Identify utilization‑management trends and take appropriate action Support of regulatory and accreditation functions (e.g., CMS, State, NCQA, URAC) and compliance for all programs Support staff by providing training, clinical consultation, 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 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 Clinical appeals Collaborate with market/product leaders to help define market strategy </l
