Remote Behavioral Medical Director, Eastern Region

Centene Corporation•Remote-MO, MA

7d•$215,000 - $408,500•Remote

About The Position

The Behavioral 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. The position conducts medical reviews related to utilization review and quality assurance, including reviews of complex, controversial, experimental, unusual, or new medical services and claims. It supports performance improvement initiatives for capitated providers; helps establish goals and policies to improve care quality and cost-effectiveness; and provides medical expertise in operating quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. The Behavioral Medical Director supports physician committees, conducts rounds to assess and coordinate care for high-risk patients, and collaborates with care management and clinical teams, network providers, appeals teams, and medical and pharmacy consultants. The role also contributes to provider network development, market expansion, physician education, utilization and quality studies, provider recommendations, and medical management programs. As needed, the position may represent the business unit before local and national publics and at state or other ad hoc committees.

Requirements

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

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.
Certification in Child Psychiatry.

Responsibilities

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 and claims; determine medical necessity and appropriate payment.
Support performance improvement initiatives for capitated providers.
Assist the Chief Medical Director in planning and establishing goals and policies to improve the quality and cost-effectiveness of care and member services.
Provide medical expertise in the operation of 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 to review 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 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.
Interface with physicians and other providers to facilitate recommendations intended to improve utilization and healthcare quality.
Develop alliances with the provider community through development and implementation of medical management programs.
Represent the business unit before local and national publics on medical philosophy, policies, and related issues as needed.
Represent the business unit at appropriate state committees and other ad hoc committees.
Work weekends and holidays as needed to support business operations.