Remote Medical Director, Appeals

Centene Corporation•Remote-MO, MO

2d•Remote

About The Position

Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making. Supports effective implementation of performance improvement initiatives for capitated providers. Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Assists the Chief Medical Director in the functioning of the physician committees including 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. Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate. Assists in the development and implementation of physician education with respect to clinical issues and policies. Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. Develops alliances with the provider community through the development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. Represents the business unit at appropriate state committees and other ad hoc committees.

Requirements

Medical Doctor or Doctor of Osteopathy.
Actively practices medicine.
Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.
Active 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.

Nice To Haves

Utilization Management experience and knowledge of quality accreditation standards preferred.
Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.
Experience treating or managing care for a culturally diverse population preferred.
Certification in Internal and / or Family Medicine specialty, preferred.

Responsibilities

Direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
Provide medical leadership for utilization management, cost containment, and medical quality improvement activities.
Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
Support effective implementation of performance improvement initiatives for capitated providers.
Assist in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
Provide medical expertise in the operation of approved quality improvement and utilization management programs.
Assist in the functioning of physician committees.
Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams.
Collaborate with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
Participate in provider network development and new market expansion.
Assist in the development and implementation of physician education.
Identify utilization review studies and evaluate adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice.
Interface with physicians and other providers to facilitate implementation of recommendations.
Review claims involving complex, controversial, or unusual or new services to determine medical necessity and appropriate payment.
Develop alliances with the provider community.
Represent the business unit before various publics on medical philosophy, policies, and related issues.
Represent the business unit at appropriate state committees and other ad hoc committees.