• Provide prior authorization medical reviews, consultation and clinical review services • Participate in peer-to-peer discussions • Provide provider education, training, data sharing, performance evaluations and orientation to the plan • Conduct clinical reviews for designated CareSource members as requested • Provide physician review for clinical appeals cases • Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns • Participate in development of policies and procedures • Participates in quality improvement initiatives, case management activities and member safety activities • Provide cross-coverage for other Medical Directors and/or markets, as needed • Oversight and quality improvement activities associated with case management activities • Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers • 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 • Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs