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 determine medical necessity and payment integrity for CareSource members.
Role type
Senior Medical Director (Clinical Review & Quality)
Builds
Clinical care standards, practice guidelines, and quality improvement plans for managed care members.
Domain
Healthcare / Managed Care / Medical Claims Review
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical case review, fraud/abuse investigation, policy development, quality improvement, utilization data analysis, regulatory compliance, provider education, clinical appeals adjudication
Preferred skills
Managed care medical review experience, primary care residency, business administration degree
Technologies
Microsoft Word
Responsibilities
Conduct clinical reviews for designated members, evaluate medical records and claims data for payment integrity, participate in fraud and quality of care investigations, develop and revise clinical care standards, support regulatory and accreditation functions, collaborate on market strategy
Seniority
Senior, hands-on IC with leadership responsibilities