Behavioral Health Medical Director

Centene Corporation•Remote-CA, NV

8d•$215,000 - $408,500

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 activities, and conducts medical reviews involving utilization, quality assurance, complex or controversial services, and medical necessity appeals. The Medical Director supports quality and cost-effectiveness initiatives, provider performance improvement, physician education, and the operation of utilization management and quality improvement programs in accordance with applicable regulatory, state, corporate, and accreditation requirements. The role also collaborates with clinical teams and network providers, conducts rounds for high-risk patients, and may represent the business unit at public and state committee forums. The position requires a board-certified psychiatrist and an unrestricted state medical license. California, Oregon, Washington, or Nevada licensure is specified; candidates living in the Pacific Time Zone are highly preferred. The physician must actively practice medicine.

Requirements

Medical Doctor (MD) or Doctor of Osteopathy (DO).
Board certification in Psychiatry is required; the posting specifies board certification by the American Board of Psychiatry and Neurology for Behavioral Health.
Current state medical license without restrictions; the posting specifies California, Oregon, Washington, or Nevada licensure and no restrictions, limitations, or sanctions from government programs.
Must actively practice medicine.

Nice To Haves

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

Responsibilities

Provide medical leadership for utilization management, cost containment, and medical quality improvement activities.
Perform medical reviews related to utilization review, quality assurance, and complex, controversial, or experimental medical services, ensuring timely and high-quality decisions.
Support implementation of performance improvement initiatives for capitated providers.
Assist the Chief Medical Director in planning and establishing goals and policies to improve care quality and cost-effectiveness for members.
Provide medical expertise in operating approved 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, appeals teams, and medical and pharmacy consultants on complex cases and medical necessity appeals.
Participate in provider network development and new market expansion as appropriate.
Assist with the development and implementation of physician education concerning clinical issues and policies.
Identify utilization review studies and evaluate adverse utilization trends, unusual provider practice patterns, and adequacy of benefit and payment components.
Identify clinical quality improvement studies to reduce unwarranted variation in clinical practice and improve quality and cost of care.
Work with physicians and other providers to implement recommendations that improve utilization and healthcare quality.
Review claims involving complex, controversial, unusual, or new services to determine medical necessity and appropriate payment.
Develop alliances with the provider community through medical management programs.
Represent the business unit before local or national audiences 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.