Behavioral Health Medical Director

Centene Corporation • Remote-MO, MO

7d • $215,000 - $408,500 • Remote

About The Position

Assist the Chief Medical Director in directing and coordinating medical management, quality improvement, and credentialing functions for the business unit. This fully remote role focuses primarily on case review, with opportunities to support education and process improvement across a variety of markets, states, lines of business, levels of care, and review types. The role requires an agile, team-oriented physician who is comfortable with variety and passionate about teaching and continuous learning.

Provide medical leadership for utilization management, cost containment, and medical quality improvement. Conduct utilization review, quality assurance, and medical review of complex, controversial, experimental, unusual, or new services to support timely, high-quality decisions about medical necessity and appropriate payment. Support implementation of performance improvement initiatives for capitated providers and help establish goals and policies that improve care quality and cost-effectiveness.

Provide medical expertise in approved quality improvement and utilization management programs consistent with regulatory, state, corporate, and accreditation requirements. Assist with physician committee structure, processes, and membership; identify utilization and quality improvement studies; evaluate adverse utilization trends, unusual provider practice patterns, and benefit or payment adequacy; and work with providers to implement recommendations that improve utilization and quality.

Collaborate with clinical teams, network providers, appeals teams, and medical and pharmacy consultants on complex cases and medical necessity appeals. Conduct regular rounds to assess and coordinate care for high-risk patients with care management teams. Support provider network development and new-market expansion as appropriate, develop physician education on clinical issues and policies, and build relationships with the provider community through medical management programs. As needed, represent the business unit before local and national audiences and at state or ad hoc committees. Weekend and holiday work may be required in support of business operations.

Requirements

• Medical Doctor (MD) or Doctor of Osteopathy (DO).
• Board certification in Psychiatry, including certification by the American Board of Psychiatry and Neurology.
• Current state medical license as an MD or DO without restrictions, limitations, or sanctions from government programs.
• Actively practices medicine.

Nice To Haves

• Addiction specialty experience.
• 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.

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 review of complex, controversial, experimental, unusual, or new services, supporting timely decisions on medical necessity and appropriate payment.
• Support effective implementation of performance improvement initiatives for capitated providers.
• Assist in setting goals and policies to improve the quality and cost-effectiveness of care and services for members.
• Provide medical expertise in approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Assist 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 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 and improve the quality and cost of care.
• Work with physicians and other providers to implement recommendations that improve utilization and healthcare quality.
• 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.

Benefits

• Competitive pay
• Health insurance
• 401(k)
• Stock purchase plans
• Tuition reimbursement
• Paid time off and holidays
• Flexible approach to work schedules, including remote, hybrid, field, or office schedules

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree