Behavioral Health Medical Director

Centene Corporation•Remote-CA, CA

About The Position

The Behavioral Health Medical Director assists the Chief Medical Director in directing and coordinating medical management, quality improvement, and credentialing functions for the business unit. The role provides medical leadership for utilization management, cost containment, and medical quality improvement, and performs reviews involving utilization, quality assurance, complex or controversial services, medical necessity, and appropriate payment. The Medical Director supports performance improvement for capitated providers; helps establish goals and policies to improve the quality and cost-effectiveness of member care; and provides expertise in operating quality improvement and utilization management programs in accordance with applicable regulatory, state, corporate, and accreditation requirements. The role also assists with physician committee operations and physician education, and collaborates with clinical teams, providers, appeals staff, and medical and pharmacy consultants. The position conducts rounds to assess and coordinate care for high-risk patients, identifies utilization and quality improvement studies, evaluates adverse utilization trends and unusual provider practice patterns, and works with providers to implement recommendations. It may participate in provider network development and market expansion, represent the business unit before public groups and committees, and may require weekend or holiday work as needed. The preferred candidate lives in the Pacific Time Zone.

Requirements

Medical Doctor (MD) or Doctor of Osteopathy (DO).
Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services.
Current, unrestricted state license as an MD or DO, without limitations or sanctions from government programs.
Must be a Board Certified Psychiatrist and licensed in California, Oregon, Washington, or Nevada.
Actively practices medicine.

Nice To Haves

Utilization Management experience and knowledge of quality accreditation standards.
Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management.
Experience treating or managing care for a culturally diverse population.
Residence in the Pacific Time Zone.

Responsibilities

Assist the Chief Medical Director in directing and coordinating medical management, quality improvement, and credentialing functions.
Provide medical leadership for utilization management, cost containment, and medical quality improvement activities.
Perform utilization review, quality assurance, and medical reviews of complex, controversial, experimental, unusual, or new services, including determinations of medical necessity and appropriate payment.
Support implementation of performance improvement initiatives for capitated providers.
Assist in planning and establishing goals and policies to improve the quality and cost-effectiveness of care and service for members.
Provide medical expertise in operating quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
Assist the Chief Medical Director with physician committee structure, processes, and membership.
Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
Collaborate with clinical teams, network providers, the appeals team, and medical and pharmacy consultants on complex cases and medical necessity appeals.
Participate in provider network development and new market expansion as appropriate.
Assist in developing and implementing physician education on clinical issues and policies.
Identify utilization review studies and evaluate adverse utilization trends, unusual provider practice patterns, and the adequacy of benefit and payment components.
Identify clinical quality improvement studies to reduce unwarranted variation in clinical practice and improve care quality and cost.
Work with physicians and other providers to implement recommendations that improve utilization and health care quality.
Develop alliances with the provider community through medical management programs.
Represent the business unit before local or national public groups on medical philosophy, policies, and related issues as needed.
Represent the business unit at appropriate state and ad hoc committees.
Work weekends and holidays as needed to support business operations.