Remote Medical Director, Inpatient Marketplace

Centene Corporation•Remote-MO, IN

1d•$215,000 - $408,500•Remote

About The Position

The 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 performs medical reviews related to utilization review, quality assurance, and complex, controversial, experimental, unusual, or new services. The position supports performance improvement initiatives for capitated providers and helps establish goals and policies to improve the quality and cost-effectiveness of care and services. It provides medical expertise for approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements, and assists with physician committee structure, processes, and membership. The Medical Director conducts regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. The role works with clinical teams, network providers, appeals teams, and medical and pharmacy consultants to review complex cases and medical necessity appeals. It may also support provider network development, market expansion, and physician education. The position identifies utilization and quality improvement studies, evaluates adverse utilization trends and unusual provider practice patterns, and works with physicians and other providers to implement recommendations that improve utilization and healthcare quality. It reviews claims to determine medical necessity and appropriate payment, develops alliances with the provider community through medical management programs, and may represent the business unit at public, state, and ad hoc committees. Weekend and holiday work may be required as needed.

Requirements

Medical Doctor (MD) or Doctor of Osteopathy (DO).
Actively practices medicine.
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.
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.
Certification in Internal or Family Medicine.
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, quality assurance, and medical reviews of complex, controversial, experimental, unusual, or new services.
Support implementation of performance improvement initiatives for capitated providers.
Assist in establishing goals and policies to improve the quality and cost-effectiveness of care and services for members.
Provide medical expertise for 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 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.
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 publics 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.