Medical Director

Centene Corporation•Remote-MO, MO

1d•$215,000 - $408,500

About The Position

Centene Corporation is hiring a full-time Medical Director to help direct and coordinate medical management, quality improvement, and credentialing functions for its business unit. The role provides medical leadership for utilization management, cost containment, and medical quality improvement, while supporting the Chief Medical Director in setting goals and policies to improve the quality and cost-effectiveness of care and service for members. The Medical Director conducts medical reviews involving utilization review, quality assurance, complex or controversial services, and medical necessity appeals. The role supports performance improvement initiatives for capitated providers, approved quality improvement and utilization management programs, physician committees, and physician education. It also works with clinical teams, network providers, appeals teams, and medical and pharmacy consultants to review complex cases and coordinate care for high-risk patients. The position may contribute to provider network development and market expansion, represent the business unit before public and state committees, and develop relationships with the provider community. Candidates must hold an unrestricted MD or DO license in one of the listed states and have board certification in a recognized medical specialty; psychiatry certification is required. The position may require weekend and holiday work as needed.

Requirements

Medical Doctor (MD) or Doctor of Osteopathy (DO).
Unrestricted current MD or DO license in one of the following states: Missouri, Illinois, Kansas, Iowa, Nebraska, Michigan, Wisconsin, Indiana, Ohio, or Pennsylvania.
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.
Psychiatry specialty certification is required.
Must actively practice medicine.
Current license must have no 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.

Responsibilities

Assist the Chief Medical Director in directing and coordinating 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 reviews related to utilization review, quality assurance, and complex, controversial, or experimental medical services, ensuring timely and quality decisions.
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 member services.
Provide medical expertise in operating 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 in collaboration with care management teams.
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 with developing and implementing physician education on clinical issues and policies.
Identify utilization review studies and evaluate adverse utilization trends, unusual provider practice patterns, and benefit or payment adequacy.
Identify clinical quality improvement studies to reduce unwarranted variation in clinical practice and improve care quality and cost.
Interface with physicians and other providers to facilitate recommendations that improve utilization and healthcare quality.
Review claims involving complex, controversial, unusual, new, or experimental services to determine medical necessity and appropriate payment.
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 and ad hoc committees.