Medical Director, Post-Service Review & Medical Claims Review (MCR)
Core
Provide clinical review services, peer-to-peer discussions, and physician review for clinical appeals and post-service audits to ensure medical necessity and payment integrity for CareSource members.
Role type
Senior Medical Director (Managed Care & Claims Review)
Builds
Clinical care standards, practice guidelines, and quality improvement initiatives for post-service review and medical claims review.
Domain
Healthcare / Managed Care / Medical Claims Review
Required skills
Clinical practice experience, Medical review, Clinical appeals, Fraud investigation, Policy development, Quality improvement, Utilization data analysis, Regulatory compliance
Preferred skills
Managed care medical review experience, Business Administration degree, Primary care residency
Technologies
Microsoft Word
Responsibilities
Conduct clinical reviews for designated members, Provide physician review for clinical appeals, Evaluate medical records and claims data for payment integrity, Participate in fraud, abuse, and quality of care investigations, Develop and revise clinical care standards and practice guidelines, Collaborate with market/product leaders to define strategy, Support regulatory and accreditation functions.
Seniority
Senior, hands-on IC